A National Study of Assisted Living for the Frail
Elderly: Results of a National Survey of Facilities

Myers Research Institute

December 14, 1999

This report was prepared under #HHS-100-94-0024 and
#HHS-100-98-0013 between HHS's ASPE/DALTCP and the Research Triangle Institute.
Additional funding was provided by American Association of Retired Persons, the
Administration on Aging, the National Institute on Aging, and the Alzheimer's
Association. For additional information about this subject, you can visit the
DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact
the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H.
Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His
e-mail address is: Gavin.Kennedy@hhs.gov.

The opinions and views expressed in this report are those of the
authors. They do not necessarily reflect the views of the Department of Health
and Human Services, the contractor or any other funding
organization.

This is the first in a series of planned reports based on data collected
from surveys of a national probability sample of assisted living facilities.
These data were collected as part of a study, "A National Study of Assisted
Living for the Frail Elderly," funded by the U.S. Department of Health and
Human Services, Office of the Assistant Secretary for Planning and Evaluation
(ASPE), with additional support provided by the AARP, the Administration on
Aging (AoA), the National Institute on Aging (NIA), and the Alzheimer's
Association.

This report presents the results of a telephone survey of a
nationally representative sample of 2,945 places identified as assisted living
facilities.

This report presents data from a telephone survey of the administrators
of assisted living facilities across the country. These facilities were
selected from a national probability sample of all facilities that met the
criteria for inclusion in the study. Thus, the findings are representative of
the industry as a whole. As such, they represent the first empirical data on
the characteristics of the assisted living industry nationwide based on a
representative national sample of facilities.

STUDY PURPOSE

The overall purpose of the study was to learn about the role assisted
living facilities play in providing a residential setting and supportive
long-term care services to the elderly. The specific objectives of this
telephone survey were to:

Determine the size and nature of the supply of assisted living
facilities

Describe the basic characteristics of the assisted living industry
particularly in terms of the services, accommodations and basic price

Begin examining the extent and way in which the current supply of
facilities embodies the key philosophical tenets of assisted living, and

Identify facilities for subsequent, more extensive data collection.

Assisted living represents a promising new model of
residential long-term care, one that blurs the sharp and invidious distinction
between receiving long-term care in one's own home and in an
"institution."

STUDY METHODS

In order to conduct the survey and obtain generalizable results, the
project staff implemented a complex, multi-stage sampling design. At the first
stage, project staff selected a random sample of 60 geographic areas, known as
first stage sampling units (FSUs). These 60 FSUs were comprised of 1,086
counties in 34 states. In these geographic areas, project staff created a
comprehensive listing of places thought to be assisted living facilities. Staff
used a combination of sources to create this list, including state licensure
agencies, industry trade associations, local and national retirement
directories, telephone book "yellow" page advertisements, and Internet
listings.

Assisted living is still "new enough that the businesses
offering it and the states that license it do not agree on a precise
definition."

Tamara
HodlewskyNational Center for Assisted Living, 1998

From this list of potential candidate facilities, project staff selected
a stratified, random sample of 2,945 places. These places were then surveyed by
telephone to determine their eligibility for the study and, if eligible, to
secure information about the facility's size, services, price and
accommodations.

Eligibility Criteria. The study's three basic eligibility
criteria were that a facility had to:

Personal assistance, defined as help with at least two of the
following: medications, bathing, or dressing.

The administrators of a sample of 2,945 candidate facilities were then
surveyed by telephone during 1998. If the candidate facility met the study
eligibility criteria specified in a set of screening questions, then the
administrator was asked to respond to questions about the facility, its size,
occupancy, accommodations, services, price and basic admission and discharge
criteria. A total of 1,251 facilities were contacted, found to be eligible, and
interviewed.

The results of this screening activity and of the more extended
telephone survey are the topic of this report. The results reported here are
statistical estimates about the universe of assisted living facilities, based
on responses from the nationally representative probability sample of
facilities that were surveyed.

RESULTS

SIZE OF THE ASSISTED LIVING INDUSTRY

There were an estimated 11,459 assisted living facilities (ALFs)
nationwide, with approximately 611,300 beds and 521,500 residents, as of the
beginning of 1998.

GENERAL CHARACTERISTICS OF THE ASSISTED LIVING
INDUSTRY

The average bed-size was 53 beds; 67 percent of the ALFs had 11-50 beds;
21 percent had 51-100 beds; and 12 percent had more than 100 beds. Facility
occupancy averaged 84 percent. The average length of time the ALFs had been in
business was 15 years, but slightly more than half (58%) of the ALFs had been
in business for 10 years or less. About one-third (32%) had been in business no
more than five years.

EXHIBIT ES1. Distribution of
Resident Units Between Rooms and Apartments2

ACCOMMODATIONS

Unit Type. A room was the dominant type of resident unit
(57%) in ALFs; 43 percent of the units were apartments.2 The most common type of room was a private
room with a full bathroom (42% of all single rooms). The most common type of
apartment was a one-bedroom, single occupancy apartment (41%).

Privacy. Most assisted living facilities offered consumers
a range of options in terms of private or shared accommodations. Only 27
percent of the facilities had all-private accommodations. A plurality of ALFs
(45%) had a mix of private and shared units. However, slightly more than
one-fourth of the ALF administrators (28%) reported that the facility had at
least one bedroom shared by three or more residents.

Although ALFs offered residents a range of options, 73 percent of all
resident units were private. Twenty-five percent of the units were
semi-private, that is, shared by two unrelated persons. Two percent of resident
units were in "ward-type" rooms that housed three or more unrelated
persons.

Bathrooms. While nearly three-quarters (73%) of the rooms
or apartments were private, slightly less than two-thirds (62%) of the units
offered a private full bathroom (i.e., toilet, sink and shower or tub). An
additional six percent of the units had a private "half" bath (i.e. toilet and
sink) but no bathing facilities except communal facilities shared with other
residents. Thus, more than one-third (38%) of all ALF units required the
resident to share a bathroom.

SERVICES AND NURSE STAFFING

General Services. Nearly all facilities provided or
arranged 24-hour staff, three meals a day, and housekeeping. More than 90
percent of the ALF administrators also reported that the facility provided
medication reminders and assistance with bathing and dressing; 88 percent of
the ALFs provided or arranged central storage of drugs or assistance with
administration of medications.

Nurse Staffing. Almost three-quarters of the ALFS (71%)
had a licensed nurse, either a registered nurse (RN) or licensed vocational
nurse (LVN), working on staff full- or part-time. Slightly more than half of
the ALFs (55%) reported having an RN on staff either full or part- time. Forty
percent of the ALFs reported having a full-time RN on staff.

Providing or Arranging Services. Administrators were also
asked whether the facility provided services with their own staff or arranged
with an outside agency for the provision of the service. With the exception of
therapies, if an ALF offered a service, such as help with bathing, dressing,
and managing medications, most provided it with their own staff. About half
(52%) of the facilities provided some care or monitoring by a licensed nurse
(RN or LPN) with their own staff, and one-quarter (25%) arranged for nursing
care with an agency. However, one in five ALF administrators (21%) reported
that the facility did not arrange or provide any care or monitoring by a
licensed nurse.

Most ALFs reported a willingness to admit residents with moderate
physical limitations, such as using a wheelchair (71%) or needing help with
locomotion (62%) (i.e., walking or using a wheelchair or cart). But fewer than
half the ALFs (44%) were willing to admit residents who needed assistance with
transfers (i.e., in or out of bed, a chair or wheelchair). Administrators also
reported that fewer than half the ALFs would admit a resident with moderate to
severe cognitive impairment (47%).3

Facilities also had criteria about the retention of residents with
certain types of conditions or problems, although, as with admission policies,
many facilities had idiosyncratic policies (see footnote
#3). Nearly one-third of the administrators (31%) reported that the ALF
would not retain a resident who used a wheelchair (or that "it depends"), and
38 percent would discharge a resident who needed assistance with locomotion.
Fewer than half (45%) of the ALFs would definitely retain a resident with
moderate to severe cognitive impairment, and 76 percent would not retain
residents with behavioral symptoms (e.g., wandering). Seventy-two percent of
the ALFs would not retain a resident who needed nursing care for more than 14
days. Nearly three-quarters of the ALFs (72%) reported that one of more of
their residents had been discharged within the last six months because the
resident needed skilled nursing care.

RESIDENT CHARACTERISTICS

ALF administrators estimated that about 24 percent of their residents
received help with three or more activities of daily living (ADLs), such as
bathing, dressing, and locomotion. They estimated that about one-third of the
residents (34%) had moderate to severe cognitive impairment.

DIFFERENT MODELS OF ASSISTED LIVING

The information provided by administrators identified two significant
variations among the ALFs that are worth noting. One group of ALFs identified
or described themselves as assisted living facilities. Another much smaller
group provided the same basic services but identified themselves by some other
designation, such as adult congregate living, residential care, or community
residential facility. Another significant variation was between ALFs that were
free-standing and ALFs located on a campus that offered multiple levels of
care. Such "multi-level" campuses typically housed an ALF and a nursing home or
some other type of residential care, such as congregate apartments or
independent living facilities.

Self-Described ALFs. Seven of ten (72%) of the administrators
represented or described the facility as being an "assisted living facility or
residence." Twenty-eight percent of the administrators did not describe the
facility as assisted living; however, the facility still met study eligibility
criteria. Despite the differences in how the administrators characterized the
facilities, the two groups of facilities were remarkably similar in terms of
their size, the services they offered, their nurse staffing, most admission and
retention criteria, and the basic characteristics of their residents.
Self-described ALFs, however, tended to have lower occupancy rates, had been in
business for a shorter period of time, were more likely to offer apartments and
private units, and were more likely to admit and retain residents who used a
wheelchair or received help with locomotion. They also tended, on average, to
have higher monthly prices.

Free-Standing ALFs Compared to ALFs Located on a Multi-Level
Campus. The majority of ALFs (55%) were free-standing, while 45 percent
were located on a campus housing multiple facilities or residential settings
offering different levels of care. ALFs on a multi-level campus had higher
occupancy rates and tended to have higher monthly prices than free-standing
ALFs. They were also more likely to have private units and apartments and to
provide or arrange more services for residents, most notably nursing care and
therapies. ALFs on multi-level campuses also tended to have higher levels of
nurse staffing than free-standing ALFs. In addition, they were more likely to
admit and retain residents who needed nursing care and residents who used a
wheelchair. Despite this, the administrators did not report having a "heavier
care" resident case mix than the free-standing ALFs.

Categorization of ALFs By Combined Levels of Service and Privacy.
Any attempt to understand assisted living and its role in providing long-term
care to the frail elderly is hindered by the lack of a common definition of
"assisted living." Currently, places known as ALFs differ widely in ownership,
auspice, size, services, staffing, accommodations, and price. Thus, analyzing
data on facilities and reaching conclusions about "assisted living" as a whole
involves comparing "apples to oranges." As a result, project staff developed a
classification that divided the universe of assisted living facilities into
distinct categories or types of facilities, representing their mix of services
and privacy. The four types the study identified represent reasonably
homogeneous groups of facilities. Moreover, the data revealed significant
differences among groups.

Definitions of high, low and minimal privacy. "High
privacy," meant that at least 80 percent of the resident units were private. A
total of 31 percent of the facilities met this definition of high privacy.
Twenty-eight percent of the ALFs offered "minimal privacy" because they had one
or more rooms that housed at least three residents. The remainder of the ALFs
(41%) fell between these two types of facilities in a "low privacy" category.

Definitions of high, low and minimal services. "High
services" was defined as having a full-time RN on staff and providing nursing
care, as needed, with facility staff, as well as providing help with at least
two ADLs, 24-hour staff, housekeeping, and at least 2 meals a day. Thirty-one
percent of the ALFs met this criterion. Five percent of the ALFs did not offer
help with even two ADLs and were thus defined as providing "minimal" services.
The remaining ALFs (65%)4 were
categorized as "low service," although some that did not provide nursing care
with their own staff were willing to arrange a higher level of services
through an outside provider, such as a home health agency.5

Combining the mix of services and privacy revealed four basic types of
ALFs. The first type of ALF combined facilities in the "minimal" group of ALFs
(i.e., the 32% with either minimal privacy or minimal services) and facilities
offering low privacy and low service (i.e., 27% of the ALFs). The combined
low/minimal privacy and services group was the most common type of assisted
living facility, comprising 59 percent of all the ALFs. This type of assisted
living facility cannot be easily distinguished from the traditional concept of
board and care homes. A significant proportion of resident rooms were shared
rather than private, and such facilities offered little beyond assistance with
medications, bathing, or dressing. In two of five (41%) ALFs described by this
model, there was at least one room shared by three or more people. Facilities
of this type not only represented the majority of all ALFs nationwide, they
also constituted 58 percent of all the facilities that described themselves as
assisted living.

Another ALF type offered a high degree of privacy in accommodations but
low services, a sort of "cruise ship" model of assisted living. In this type of
ALF, more than 80 percent of the accommodations were private. However, these
facilities would have had a difficult time helping residents age in place,
since they had no RN on staff and most were unwilling or unable to provide or
arrange any nursing care for residents. Only 19 percent of the ALFs in this
model would provide or arrange nursing care and retain a resident who needed
such care. This ALF type comprised 18 percent of all ALFs nationwide.

A third type of ALF was one described as high service/low privacy. In
such facilities, two-thirds of the accommodations were in single rooms rather
than apartments, and fewer than 80 percent of the rooms were private. However,
all such facilities had a full-time RN on staff. About half (53%) the ALFs of
this type were willing to provide or arrange nursing care, as needed, and
retain residents who needed such care. This was also the type of ALF that had
the most expansive admission and retention criteria and the highest resident
acuity. For example, such facilities were more likely to retain residents who
needed assistance with transfers and to retain residents who needed nursing
care. Compared to the other ALF types, the high service/low privacy type also
had a much higher proportion (35%) of residents who received assistance with
three or more activities of daily living (ADLs), such as help with locomotion
or using the toilet, as well as bathing and dressing. An estimated 12 percent
of the ALFs across the country were in this category.

A fourth type of ALF offered high service and high privacy. Only 11
percent of all ALFs fell into this category. While resident accommodations were
almost evenly split between rooms and apartments, nearly all (98%) of the
accommodations were private. In addition, 41 percent of the high service/high
privacy ALFs offered to arrange or provide nursing care and retain residents
who needed such care. All had an RN on staff.

PRICE OF ASSISTED LIVING

There were many variations in pricing structure among the ALFs
nationwide. Some ALFs had a single monthly price for what they defined as basic
services and accommodations. Other ALFs had multiple rates, varying with either
the type of accommodation or the service package provided to the resident.

The most common monthly basic price was between $1000 and $1999
for both facilities with a single rate (i.e., 45% were in this range) and
facilities with multiple rates (i.e., the range covered the most common rate
for 52% of the ALFs). Thus, the most common basic price was between $12,000 and
$24,000 per year. However, it is important to note that the average price was
depressed by the presence of a very large number of ALFs (59%) that offered
minimal or low privacy and services and had relatively low monthly rates. The
most common base price for facilities with multiple rates was just over $22,000
per year for the high service/low privacy ALFs and just over $21,000 for the
high privacy/low service ALFs. The basic annual charge was slightly more than
$23,000 for the high service/high privacy ALFs.

These rates are striking for two reasons. First, in many ALFs, they do
not cover all services. Residents often pay extra for such services as
medication administration, transportation, and any assistance with ADLs or
nursing care above the minimum covered by the basic rate in a facility.

Second, the rates are largely out of reach for most low-income older
persons and unaffordable for many moderate-income elderly, unless they
supplement their income with additional funds generated by disposal of their
assets. According to data from the U.S. Bureau of the Census,6 40 percent of persons aged 75 and
older had incomes in 1997 of less than $10,000 per year. Eight-four percent of
persons aged 75 and older had incomes of less than $25,000 per year in 1997.
This would make the average high service ALF or the average high privacy ALF
unaffordable for the vast majority of older persons, particularly since they
must also pay for other basic needs (e.g., supplemental insurance, out-of
pocket spending on health care and medications, clothing).7

Even if some facilities embody the key tenets of assisted
living's philosophical model, that is, policies emphasizing autonomy, dignity,
and service flexibility that facilitate maximum independence and
aging-in-place, the degree to which this model predominates in the industry is
unknown.

CONCLUSIONS

WHAT IS ASSISTED LIVING?

Any attempt to understand assisted living and its role in providing
long-term care to the frail elderly is hindered by the lack of a common
definition of "assisted living." Places known as ALFs differed widely in
ownership, auspice, size, and philosophy. Indeed, the results of this national
survey identified four different types of ALFs within the industry that had
very different patterns with respect to accommodations, services, staffing,
policies on admission and retention of residents, and price. Some of these
types, such as those offering high privacy and the high privacy/high service
ALF, appeared to be consistent with the philosophy of assisted living. Other
types, such as the low-minimal privacy/low service types were much closer to
the traditional concept of domiciliary care or board and care, with few
services and relatively little privacy.

DOES THE ENVIRONMENT OF ALFS MATCH THE PHILOSOPHY OF ASSISTED
LIVING?

The answer to this question is mixed. On the one hand, residents of
assisted living facilities had considerably more privacy and choice than
residents of most nursing homes and the majority of board and care homes. On
the other hand, there was significant variability within the assisted living
industry, and a substantial segment of the industry provided environments that
did not appear consistent with the environmental aspects of the assisted living
philosophy.

DO ALF SERVICES MATCH THE PHILOSOPHY OF ASSISTED
LIVING?

The ability of assisted living facilities to meet health-related
unscheduled needs of residents is still an open question - in part because of
facility policies (e.g., staffing, retention criteria or discharge policies)
and in part because of potential constraints imposed by state licensure
regulations.

CAN ALF RESIDENTS AGE IN PLACE?

The answer depends on one's concept of aging in place. For example, in
most ALFs, a resident could move from relative independence (e.g., needing or
wanting only meal preparation, housekeeping, and staff that can respond to
emergencies) to a more complex stage at which the resident needed help with
bathing, dressing, and managing medications and used a wheelchair to get
around. If this "span" or change in needs were the definition of "aging in
place," then the admission and retention policies of ALFs suggested that they
were willing to allow residents to age in place.

On the other hand, if aging in place meant that the average consumer
could select an assisted living facility and reasonably expect to live there to
the end of his or her life, regardless of changes in health or physical and
cognitive functioning, then the answer must be "no." In most ALFs, a resident
whose functional limitations necessitated help with transfers or whose
cognitive impairment progressed from mild to moderate or severe or who
exhibited behavioral symptoms would be discharged from the facility. The same
was true for a resident who needed nursing care for more than two weeks.

Thus, there was a limitation in terms of the ability of ALF residents to
age in place.

IS ASSISTED LIVING AFFORDABLE FOR LOW AND MODERATE INCOME OLDER
PERSONS?

Assisted living was largely not affordable for moderate and low-income
persons aged 75 or older unless they disposed of their assets and spent them
down to supplement their income. Further, to the degree that some assisted
living facilities were affordable for low- and moderate-income older persons,
they were more likely to be ALFs categorized as low-minimal service/low-minimal
privacy facilities.

A variety of demographic factors and policy initiatives have led to
increased demand for residential facilities that offer supportive services for
the frail elderly. These factors include:

A rapidly growing elderly population with significant levels of
physical disability and mental impairment;

A strong preference of the elderly for in-home and community-based
services rather than nursing homes;

Incentives at the state level to constrain the use of nursing
homes.

Board and care homes are known by different names across the
states, including:

Personal care homes

Residential care facilities for the
elderly

Adult congregate living
facilities

Homes for the aged

Domiciliary care homes

Assisted living
facilities

Although families continue to be the major source of long-term care, a
variety of residential settings with supportive services have emerged to
supplement their efforts. These arrangements support those families whose
members need more care than the family can provide and the elderly and disabled
who have no family. Other than nursing homes, the most common form of
residential setting with services for people with disabilities is the entity
generically known as "board and care" homes. This term is used in a variety of
ways across the states; however, in general "board and care" refers to
non-medical community-based residential settings that house two or more
unrelated adults and provide some services such as meals, medication
supervision or reminders, organized activities, transportation, or help with
bathing, dressing, and other activities of daily living (ADLs).

1.1 BACKGROUND ON RESIDENTIAL CARE FOR THE ELDERLY

In most states, entities known as "assisted living" have been considered
part of the residential care or board and care home sector. Board and care or
residential care are the generic terms often used to describe various types of
housing with supportive long-term care services, exclusive of licensed nursing
homes. Board and care homes are regulated at the state level, and each state
has different definitions and names for these facilities.8 The best estimate is that there
are more than thirty names for licensed residential care facilities, and they
are regulated by more than sixty different state agencies (Hawes, Wildfire and
Lux, 1993; Mollica, 1998). In addition, more recently, many states have renamed
or expanded the category of residential care facilities to include a specific
category known as "assisted living" (Mollica, 1998).

"In general, assisted living combines housing, personal
services, and nursing and health care in an environment that promotes maximum
independence, privacy and choice for people too frail to live alone but too
healthy to utilize 24-hour nursing care."

Tamara Hodlewsky, National
Center on Assisted Living, 1998

Traditionally, board and care homes served a mixed population of
residents. These homes fell into one of three basic types of licensed
facilities (Clark et al., 1994): (1) homes serving residents with mental
retardation or developmental disabilities; (2) homes serving residents with
mental illness; and (3) homes serving a mixed population of physically frail
elderly, cognitively impaired elderly, and persons with mental health problems
(Clark et al., 1994). Most board and care homes fell into this last category,
but many still cared for residents with a wide range of needs and disabilities,
including sizeable numbers of persons with psychiatric conditions. Assisted
living facilities, however, mainly serve only the frail elderly.

1.2 EMERGENCE AND GROWTH OF ASSISTED LIVING

Starting in the late 1980s and early 1990s, this population of board and
care homes expanded to include a growing number of facilities that identified
themselves as "assisted living facilities," although most states did not have a
specific licensure category with this designation. According to estimates
generated from the National Health Provider Inventory based on a 1991 survey,
there were an estimated 34,000 licensed board and care homes in the United
States, including facilities known as assisted living, with more than 613,000
beds (Clark et al., 1994). A 1991/92 survey of state licensing agencies found a
higher number, with an estimated 34,000 homes serving only older persons
(Hawes, Wildfire and Lux, 1993). Added to this were an unknown number of
unlicensed homes, some of which were assisted living facilities. A ten-state
study that enumerated unlicensed homes estimated that, on average, the supply
of unlicensed homes in 1993 was about 12 percent of the licensed supply serving
a mainly elderly population (or elderly/mixed) (Hawes et al., 1995a). Applying
this estimate to the nation would mean that, as of 1993, there were probably
38,000 licensed and unlicensed residential care homes with something between
800,000 and 900,000 beds serving an elderly/mixed population. Adding an
estimated 7,000 places serving only persons with persistent mental illness or
developmental disabilities brought the estimated total of all residential care
beds to nearly one million (Clark et al., 1994; Hawes et al., 1995; Hawes,
Wildfire and Lux, 1993; U.S. House, 1989). As a point of comparison, there were
an estimated 17,000 licensed nursing homes with approximately 1.68 million beds
serving more than 1.5 million nursing home residents (DuNah et al., 1993).

This supply of residential care facilities significantly expanded with
the recent growth of assisted living facilities. By the mid-1990s, the most
rapidly expanding type of residential care was among facilities known as
"assisted living." Assisted living originally developed as a Scandinavian model
of residential long-term care, emphasizing the importance of the social aspects
of care and departing from what is generally termed a "medical" model or
organization of the care setting (Coleman, 1995). Essentially, the goal of a
social model of care is to create a normal, homelike living environment that is
organized around promoting independence rather than the provision of health
care services or performance of personal care assistance tasks.

1.2.1 What Is the Philosophy of Assisted
Living

Assisted living means different things to different people, but there is
general agreement on the key aspects of what constitutes assisted living. For
example, one commonly accepted definition has been offered by Kane and Wilson
(1993):

Any residential group program that is not licensed as a nursing
home, that provides personal care to persons with need for assistance in daily
living, and that can respond to unscheduled needs for assistance.

The key philosophical principles or tenets that distinguish
assisted living are:

Services and oversight available
24-hours a day

Services to meet scheduled and
unscheduled needs

Care & services provided or
arranged so as to promote independence

An emphasis on consumer dignity,
autonomy and choice

An emphasis on privacy and a homelike
environment

A similar but more expansive definition was specified by the Assisted
Living Quality Coalition. This coalition is a group representing consumer
groups (the Alzheimer's Association and AARP) and provider associations (the
American Association of Homes and Services for the Aging [AAHSA], the Assisted
Living Federation of America [ALFA], the American Seniors Housing Association
[ASHA], and the American Health Care Association's [AHCA]/ National Center for
Assisted Living [NCAL]). According to the Coalition, an assisted living setting
is:

A congregate residential setting that provides or coordinates
personal services, 24-hour supervision and assistance (scheduled and
unscheduled), activities, and health related services; designed to minimize the
need to move; designed to accommodate individual residents' changing needs and
preferences; designed to maximize residents' dignity, autonomy, privacy,
independence, and safety; and designed to encourage family and community
involvement.

As would be expected, the provider associations that belong to the
Coalition espouse definitions that are very much in line with the Coalition's.
For example, ALFA defined an "assisted living" residence as:

A special combination of housing, supportive services, personalized
assistance and healthcare designed to respond to the individual needs of those
who need help with activities of daily living (ADLs) and instrumental
activities of daily living (IADLs). Supportive services are available, 24 hours
a day, to meet scheduled and unscheduled needs, in a way that promotes maximum
dignity and independence for each resident and involves the resident's family,
neighbors and friends (ALFA, 1996).

AAHSA also emphasized the central tenets of choice, privacy and dignity
and noted that in assisted living, services may be provided or arranged:

Assisted living is a program that provides and/or arranges for the
provision of daily meals, personal and other supportive services, health care
and 24-hour oversight to persons residing in a group residential facility who
need assistance with activities of daily living and instrumental activities of
daily living. It is characterized by a philosophy of service provision that is
consumer driven, flexible and individualized and maximizes consumer
independence, choice, privacy and dignity (Gulyas, 1997).

"The Coalition believes that, more than any other type of
long-term care service, assisted living must be driven by a philosophy that
emphasizes personal dignity, autonomy, independence, and privacy in the least
restrictive environment. Further, it should enhance a person's ability to 'age
in place'..."

Assisted Living Quality
Coalition, 1998

Similarly, an investment banking firm defined assisted living as:

A combination of housing and services provided in facilities that
are designed as multi-unit properties containing communal dining and recreation
areas. The facilities offer a broad spectrum of continuous or as-needed
services to elderly senior citizens in an effort to promote their independence
and personal dignity while replicating a safe and home-like environment for
them to age in place (Conway et al., 1997).

Finally, the National Center for Assisted Living noted an important
distinction regarding the place of assisted living in the continuum of
long-term care services:

Assisted living represents an option of care that is generally less
than that provided by and required of skilled nursing facilities but more than
is offered by independent living apartment complexes (Hodlewsky, 1998).

In summary, there is substantial agreement among provider and consumer
groups about the key elements of the assisted living philosophy. Moreover,
some, like the Assisted Living Quality Coalition, argue that some of these
elements or principles distinguish it from other types of long-term care. There
is less agreement on the degree to which the current industry embodies those
principles.

1.2.2 Variability Among "Assisted Living" Facilities

In the view of many observers in the United States, assisted living
facilities represent a promising new model of long-term care, one that blurs
the sharp and invidious distinction between nursing homes and community-based
long-term care and reduces the chasm between receiving long-term care in one's
own home and in an "institution." In addition, assisted living facilities are
thought to provide (or be capable of providing) a range of long-term care
services that makes them a viable but less institutional alternative to nursing
homes (Kane & Wilson, 1993; Mollica and Snow, 1996; Wilson, 1993).

"Assisted living is known by dozens of different terms
throughout the country. ...The multitude of names for assisted living reflects
the diversity of services offered in the cloudy nexus between retirement
housing and skilled nursing care."

Tamara Hodlewsky, National
Center for Assisted Living, 1998

Other observers hold a more jaundiced view of the performance of the
industry. First, some evidence suggests that assisted living predominantly
serves a private-pay market of well-to-do elderly. If true, this would make its
reality more limited than its promise. In addition, there is ample evidence of
considerable variability in the ownership, auspice, operation, size, service
package, physical plant, and client orientation in the industry (Manard et al.,
1992). Indeed, even among industry trade associations there is no uniformity
among the various facilities known as assisted living. For example, members of
ALFA include both "purpose-built" assisted living facilities with private
apartments and providers from the National Association of Residential Care
Facilities (NARCF), which merged with ALFA. NARCF represented older, more
traditional board and care homes in which the predominant accommodation is in a
semi-private bedroom. Thus, even within ALFA, there is considerable variation.
As the National Center on Assisted Living observes:

Assisted living...is known by dozens of different terms throughout
the country...The multitude of names for assisted living reflects the diversity
of services offered in the cloudy nexus between retirement housing and skilled
nursing care (Hodlewsky, 1998).

Many places that call themselves assisted living are licensed as board
and care homes and look like board and care homes. Others are "purpose-built"
assisted living facilities whose physical plant and other environmental
characteristics are quite distinct from most board and care homes. However,
even in purpose-built facilities, studies find tremendous variability in their
basic policies, the services they provide, their approach to care, and the
resident population they serve. Indeed, many assisted living facilities look
very similar to what have traditionally been known as board and care homes
(Hawes et al., 1995b; Kane and Wilson, 1993; Lux, 1995).

Even if some facilities embody the key tenets of assisted
living's philosophical model, that is policies emphasizing autonomy, dignity,
and service flexibility that facilitate maximum independence and
aging-in-place, the degree to which this model predominates in the industry is
unknown.

Given these factors, there is likely to be considerable variation in how
assisted living facilities define their role and how they operationalize key
concepts of consumer autonomy and choice. Evidence from a prior survey of ALF
administrators found that there was substantial variation in policies and
practices on several issues thought to be related to consumer autonomy and
choice. For example, almost half the facilities surveyed by Kane and Wilson
(1993) reported they had assigned seating of residents at meals; 60 percent
reported they did not require staff to knock on residents' doors before
entering their rooms or apartments. Only half allowed overnight guests in the
tenant's room/apartment. Only 14 percent said that it was the tenant's choice
to refuse services, and one-third said such refusal was grounds for discharge.

In short, there are significant variations in the environment, services,
and policies about resident autonomy among facilities known as "assisted
living." Thus, even if some assisted living facilities embody the key tenets of
assisted living's philosophical model, that is, the autonomy, dignity, and
service flexibility that facilitates maximum independence and aging-in-place,
the degree to which this model predominates or is even widespread in the
industry is unknown.

There are several reasons for this variability. First, assisted living
has not developed in an orderly, planned manner. It began largely as a market
phenomenon, one thought to be responsive to consumer preferences and local
conditions, rather than a planned outgrowth of public policy (i.e., regulatory
and reimbursement policy) (Kane and Wilson, 1993; Manard et al., 1992; Mollica
and Snow, 1996). Second, there are no federal regulations, oversight , or
federal minimum standards for assisted living. Instead, regulation, where it
exists, is a state responsibility. As a result, there has been enormous
variation across the country in (a) the degree to which assisted living
facilities are regulated and (b) the way they are regulated (Mollica and Snow,
1996; Mollica, 1998). Third, to some degree, the term "assisted living" may be
more significant as a marketing tool than as a useful descriptor of a facility
that distinguishes it from other residential care settings. For example, as
previously noted, many of the members of ALFA were formerly members of the
National Association of Residential Care Facilities (NARCF), but assisted
living has been viewed as the more appealing "name." Thus, many members simply
began calling themselves assisted living rather than residential care
facilities.

In the sections that follow, we describe the expansion of assisted
living and the emerging role of public policy in fueling and shaping that
growth.

1.2.3 Growth of Assisted Living

From its start in the United States in the late 1980s, mainly in Oregon,
assisted living has become the most rapidly growing source of residential care
for the elderly (American Seniors Housing Association [ASHA], 1998; Citro and
Hermanson, 1999; Mollica, 1998). For example, construction of housing for
seniors grew by 11 percent between 1997 and 1998,9 with assisted living residences dominating the
new construction. Indeed, assisted living represented three-quarters of all new
senior housing construction (ASHA, 1998). This pattern of rapid growth has been
particularly striking among larger assisted living facilities (>25
beds) and among high-profile, publicly-traded multi-facility systems. For these
firms, such as Sunrise, Assisted Living Concepts, Marriott, and American
Retirement Villas, more than half their total supply of facilities were
developed or acquired in a five-year period between 1991 and 1996.

Several factors have fueled the growth of assisted living,
including:

The aging of the
population

Consumer demand

Changing health care delivery &
service practices

Advances in civil rights for persons
with disabilities

Public policies, particularly those
aimed at limiting nursing home use

State interest in substituting other
forms of residential care for nursing home care

Availability of financing for
construction and conversion

This growth has been, in no small measure, the product of investor
interest in fabled returns being earned by some firms. For example, The
SeniorCare Investor ranked one of the major assisted living corporations as
having the most outstanding stock market performance in 1998. This firm had a
return to shareholders of 159 percent, a rate that far outstripped the rates
achieved by firms concentrated in nursing homes, subacute care, and traditional
residential care facilities (SeniorCare, 1998). In fact, in 1997-98, seven of
the top ten stock market performers in the area of senior care were assisted
living companies, with an average return for the group of 47 percent
(SeniorCare, 1998).

Predictably, stock analysts were bullish about assisted living.
Fortune magazine identified assisted living as one of the top three
potential growth industries for 1997 (GAO, 1997). Similarly, the investment
banking firm of Salomon Brothers reported in 1997, "we are enthusiastic about
the sector and the underlying factors driving its explosive growth" (Conway,
MacPherson and Sfiroudis, 1997). As a result, both the stock market and lenders
provided considerable support to companies wishing to expand (Conway,
MacPherson and Sfiroudis, 1997; Leaman, 1998; Meyer, 1998; Manard and Cameron,
1997).10

Despite this growth and soaring interest among lenders and developers in
the mid-1990s, assisted living is still "new enough that the businesses
offering it and the states that license it do not agree on a precise
definition," as observed by the National Center for Assisted Living (Hodlewsky,
1998).

1.2.4 Expansion of State Involvement in Assisted
Living

The last decade has seen a tremendous expansion in state activity
regulating and paying for assisted living; however, this has led to greater
variability rather than a common definition of what assisted living is or
should be.

No consensus has emerged among state policy-makers on the
appropriate regulatory model for assisted living.

While assisted living initially developed as a market phenomenon in the
absence of much regulation or public financing (except for Oregon), states have
moved fairly rapidly to develop and implement assisted living regulations. The
first licensure regulation specifically directed at assisted living was in
Oregon in 1989. By 1992, fewer than 10 states had such regulations in place. By
1994, 14 states had developed regulations or enacted legislative statutes. By
the summer of 1996, that had grown to 22 states, with an additional 10 states
having study commissions addressing how to regulate and pay for assisted
living. Further, the number of states providing some type of Medicaid funding
for Medicaid eligible elderly in assisted living facilities (mainly through
Medicaid waiver programs) grew from 10 to 21 between 1994 and 1996. Indeed, by
1996, when combining all State activities -- legislation, current regulation,
study commissions, and Medicaid funding -- only 14 states had no activity
related to assisted living (Mollica and Snow, 1996).

By 1998, 30 states had passed legislation or issued regulations, and 22
states had licensing regulations using the term "assisted living," up from 15
in 1996. Other states were considering draft regulations or revising their
regulations, and 35 states reimburse or plan to reimburse services in assisted
living or board and care facilities as a Medicaid-covered service (Mollica,
1998).

Although there has been increasing state policy activity, to date, no
consensus has emerged on the appropriate regulatory model for assisted living.
As Mollica and Snow noted (1996), the models varied. In some states, policies
sought to create assisted living as a unique long-term care arrangement, with
distinctive environmental features (e.g., requiring that assisted living
facilities provide apartments with kitchens). Other states, however, basically
allowed the same types of accommodations and services as board and care homes
(Mollica, 1998). In addition, states differed on whether the features that
ought to be subject to regulation should include the housing component or
should be limited to only the service component, in effect treating assisted
living as a kind of "home health" service (Mollica, 1998; Mollica and Snow,
1996). Thus, regulation was a contributor to the emergence of different models
of assisted living around the country, leading to a lack of uniformity on
environment, services, and other policies. As Mollica and Snow (1996) observed:

A common definition or understanding of assisted living grows
increasingly unlikely as state policy makers, legislators, consumers and
providers develop models that address local circumstances.

Despite this variation, states have clearly been interested in expanding
the use of assisted living and other residential settings that offer supportive
long-term care services. In part, states have been interested because some
research suggested that housing with supportive services could be a
cost-effective alternative to nursing homes (Leon, Cheng, and Neumann, 1998;
Mor, Sherwood and Gutkin, 1986). It also appears that some states substituted
residential care beds for nursing home beds in their long-term care system
(Hawes et al., 1993; Hawes et al., 1995c).

In addition to creating new licensure categories and expanding Medicaid
waiver programs, many states began making more aggressive use of Medicaid
personal care service payments for residents in board and care homes
(Harrington and DuNah, 1994; Mollica, 1998). Further, they have started
allowing higher levels of care to be provided outside nursing homes. For
example, the majority of state licensing agencies allow board and care homes to
house residents who are chair-fast because of health problems or who use
wheelchairs to get around inside the facility. Indeed, even in the early 1990s,
one-third of the licensing agencies allowed board and care homes to retain
residents who were bedfast (Hawes, Wildfire and Lux, 1993). Some states also
embarked on more aggressive strategies for expanding the potential role of
board and care homes and assisted living facilities by permitting the provision
of daily or intermittent nursing care (including skilled care) and hospice care
(Hawes, Wildfire and Lux, 1993; Kane and Wilson, 1993; Manard et al., 1992;
Mollica, 1998; Mollica and Snow, 1996; Newcomer, Wilson and Lee, 1997).

1.3 REASONS FOR THE STUDY

Given the promise of the philosophy of assisted living and its rapid
growth, as well as the forces that have contributed to tremendous variability
across the country, there is natural interest in the role assisted living can
play in meeting the long-term care needs of the elderly. In addition, there are
natural concerns about the quality of care and consumer protection issues
(Cody, 1996; Hawes et al., 1995a; Hawes et al., 1997; US-GAO, 1997; 1999).
Thus, a number of public and private agencies have recently initiated studies
of assisted living.11

This report presents the results of a telephone survey of a
nationally representative sample of 2,945 places identified as assisted living
facilities.

This is the first in a series of planned reports based on data
collected from a survey of a national probability sample of 2,945 places
thought to be assisted living facilities. These data were collected as part of
a study, "A National Study of Assisted Living for the Frail Elderly."
This study was initiated and funded by the U.S. Department of Health and Human
Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE).
Additional support for the project has been provided by AARP, the
Administration on Aging (AoA), the National Institute on Aging (NIA), and the
Alzheimer's Association.

Both ASPE and AARP have a long-standing interest in the potential of
housing with supportive services, including board and care homes and assisted
living facilities, to meet the needs of aged and disabled persons for
residential long-term care services. ASPE commissioned a study in the early
1980s by Denver Research Institute (DRI) that described board and care homes
and residents in five States and investigated the effect of regulation on
quality of care (Dittmar and Smith, 1983). Other studies during the 1980s also
attempted to describe homes and residents, the regulation of these homes by
States, and the role these facilities play in providing long-term care (i.e.,
Mor, Sherwood and Gutkin, 1986; Sherwood, Mor, and Gutkin, 1981; Reichstein and
Bergofsky, 1980).

In the early 1990s, both ASPE and AARP initiated a new examination of
board and care homes and their role in the long-term care system. Specifically,
they supported studies that examined the supply (Manard et al., 1990);
described regulatory systems (Hawes, Wildfire and Lux, 1993); and described the
facilities, residents, and staff (Hawes et al., 1995b). Finally, ASPE sponsored
a study of the effects of regulation on quality in licensed and unlicensed
homes, including a sizeable number of assisted living facilities (Hawes et al.,
1995a).

ASPE and AARP placed a high priority on examining board and care homes,
quality, and regulatory effectiveness for several reasons. These included
increased state and federal expenditures on home and community-based care,
growing disability among residents, concerns about inadequate quality, and
questions about the effectiveness of state regulatory efforts.

While those were the major reasons for examining board and care homes,
ASPE and AARP's interest in assisted living has been rooted more in its promise
for meeting the needs of frail elders while enhancing the quality of their
lives. In particular, they are interested in determining the role ALFs play in
meeting the needs of the frail elderly and where assisted living fits in the
long-term care "continuum," an issue displayed in Exhibit
1.

EXHIBIT 1. Hypothesized Relationship
Between Assisted Living and Other Types of Residential Long-Term Care

Associated with this over-arching issue are a host of questions about
the role of assisted living, some addressed by this study and some by other
ongoing studies of assisted living. These questions include:

What are trends in demand and supply and what factors affect
them

What is the meaning of "quality" in assisted living; how do
residents and families define quality

What features of assisted living are most valued by residents and
families

How do consumers select assisted living and what are key consumer
protection issues

Are residents able to age in place in ALFs

Do ALFs serve low and moderate income elderly To what extent do
ALFs serve as a viable substitute for nursing homes

What is the relationship between traditional board and care homes
and their newer incarnation, assisted living facilities

To what degree does the current industry embody the philosophy of
assisted living

How are personal and health care services organized and
provided

What is the effect of various arrangements (services and privacy) on
such factors as consumer satisfaction, length of stay, cost, case mix

What is the total cost of assisted living, including ancillary
services

What is the impact of the use of assisted living on Medicare and
Medicaid

In addition, the phenomenal growth in the supply of facilities that
advertise themselves as "assisted living" has augmented ASPE and AARP's
interest in issues related to demand, supply and quality in assisted living.
The result has been a number of projects and reports sponsored by ASPE and
AARP. These ongoing interests also led to the funding of the current project.

1.4 ORGANIZATION OF THE REPORT

The remainder of the report focuses on the current study.

Section 2 describes the overall study goals
and the specific objectives of the telephone screening and survey. It also
presents a brief overview of the study methods.

Section 3 presents general descriptive data
on the industry, based on the results of this telephone survey.

Section 4 discusses the accommodations
provided by the assisted living industry.

Section 9 discusses the implications of the
study findings, particularly in terms of the degree to which the
characteristics of the industry conform to the basic philosophical principles
of assisted living.

The Myers Research Institute at Menorah Park Center for Senior Living
and Research Triangle Institute (RTI) collaborated on this effort to examine
the role of assisted living for the frail elderly.12

2.1 STUDY GOALS

The National Study of Assisted Living for the Frail Elderly was
designed to achieve the following objectives:

To identify trends in demand for and supply of assisted living
facilities;

To identify barriers to the development of assisted living and
factors that contribute to those trends in demand and supply;

To determine the extent to which the current supply matches the
central philosophical and environmental tenets embodied in the concept of
"assisted living" and to describe the key characteristics of the universe of
assisted living facilities; and

To examine the effect of key features that embody the philosophical
tenets on selected outcomes, including resident satisfaction, autonomy,
affordability, and potential to provide nursing home level of care.

To achieve these objectives, the project team implemented a number of
activities and issued several reports that are available from ASPE.13 In addition, the project team
will issue subsequent reports on the characteristics of the assisted living
industry and its staff, as well as the residents. These are based on data
collected during site visits to 300 facilities and interviews with
administrators, staff caregivers, residents, and family members. Project staff
will also interview and report on the experiences of a sample of discharged
residents or their next-of-kin.14 However, the current report addresses only
the results of a telephone survey of administrators in 2,945 places thought to
be assisted living facilities.

2.1.1 Specific Objectives of the Telephone Survey

The specific objectives of this telephone survey were to:

Screen a listing of places thought to be assisted living facilities
and determine their eligibility for the study

Determine the size and nature of the supply of assisted living
facilities

Describe the basic characteristics of the industry particularly in
terms of the services, accommodations and price

Begin examining the extent to which the current industry embodies
the key philosophical tenets of assisted living

Identify facilities for subsequent, more extensive data
collection.

2.2 SAMPLE DESIGN

To accomplish the objectives of the initial telephone survey, project
staff (1) implemented a complex sample design; (2) created a comprehensive list
of potentially eligible facilities; (3) determined whether a sample of
facilities on the list met study eligibility criteria; (4) conducted a
telephone survey of eligible facilities; and (5) analyzed the data. This
section of the report provides a brief overview of these activities. Other
reports will provide greater detail about study methods.15

2.2.1 Sample Design for the Telephone Screening and
Survey

In order to conduct the survey and to obtain results that could be
generalized to the nation as a whole, project staff implemented a stratified,
multi-stage national probability sample. At the first stage, a random sample of
geographic areas, known as first stage sampling units (FSUs), were selected. At
the second stage of sampling, staff selected a sample of facilities.16

The sample design called for selection of a set of geographic areas
prior to selecting the facility sample for several reasons. First, in order to
conduct the survey, staff had to construct a listing of assisted living
facilities. There is no national list that is comprehensive and exhaustive.
Moreover, as noted earlier, definitions of assisted living vary across the
states. In some states, there are no limits on the type of facility that may
call itself "assisted living" or advertise that it provides assisted living,
regardless of the kind of services and accommodations it provides. Further,
some states did not have a licensure category known as "assisted
living."17 As a result,
the study could not rely on state licensure lists to provide a comprehensive
and exhaustive listing of assisted living facilities. Some places meeting study
criteria would be missed, while other facilities licensed under the category of
"assisted living" might not meet more commonly understood definitions of
assisted living.

Lists from established trade associations were also insufficient as a
sampling frame. First, while there are multiple trade associations, their
combined membership accounts for an unknown proportion of the total number of
assisted living facilities (ALFs) in operation. Second, ALFA merged with the
association that represented board and care homes (i.e., the National
Association of Residential Care Facilities). As a result, the membership of
ALFA was expected to include both assisted living facilities and places that
are more traditionally thought of as board and care homes, some of which would
meet study criteria and some which might not.

Further, the study could not rely solely on retirement directories or
local advertisements, since they appeared to have differing definitions (or no
criteria) for what should be classified as assisted living. Similarly, in many
localities, there were no restrictions on the kinds of places that could call
themselves "assisted living."

As a result, a crucial aspect of the sampling design was the development
of an enumeration strategy that would enable selection of a nationally
representative sample of ALFs. However, because of the extensive level of
effort involved, creating a comprehensive list at the national level (i.e., in
each of the >3,000 counties) would have been prohibitively expensive for
this project. Thus, project staff decided to select a random sample of
geographic areas across the country in which to enumerate an exhaustive list of
facilities.18 This
involved a two-stage enumeration and screening process to provide comprehensive
coverage of the target population of assisted living facilities.

2.2.1.1 Creating a List of ALFs

In order to create a list or sampling frame of assisted living
facilities, project staff first had to define the relevant study population.
These are the criteria used to determine whether a place was eligible for
inclusion in the study. As noted, the definition of assisted living was
variable across the country. Thus, to define "assisted living" for this study,
project staff specified selected features about which there was general
agreement among industry and consumer groups that the feature was
characteristic of "assisted living."

2.2.1.1.1 Eligibility Criteria

The project's first criterion was that to be eligible for this study, a
facility had to serve a mainly elderly population. Second, it had to have more
than 10 beds.

ELIGIBILITY
CRITERIA

To be eligible for the study,
a facility had to:

1. Serve a mainly elderly
resident population2. Have more than 10
beds

AND Either

3a. Be a self-described ALF

OR

3b. Provide

24-hour staff

Housekeeping

At least 2 meals per
day

Help with at least 2 of the
following: medications, bathing or dressing

There were several reasons for this size restriction. First, we had
several reasons for expecting that small facilities would not meet study
criteria. A 1993 survey funded by DHHS/ASPE examined board and care homes in
ten states (Hawes et al., 1995b). Two-thirds of the board and care homes had 10
or fewer beds. Few of those facilities identified themselves as assisted living
or provided personal assistance with two or more activities of daily living
(ADLs). In addition, during the period of sampling, none of the states that had
specific licensure categories known as assisted living had licensed facilities
with fewer than 11 beds. Thus, project staff expected that few small facilities
would meet the service-related criteria. Second, small homes tended to have
significant numbers of non-elderly residents and were more likely to have
residents with mental retardation, developmental disabilities, and persistent
and serious mental illness. These findings were consistent with those of other
studies (e.g., Dittmar and Smith, 1983; Hawes et al., 1995c; Sherwood and
Seltzer, 1981; Sherwood, Mor and Gutkin, 1981). Finally, the small homes were
well-described in the prior study. As a result of all these factors, ASPE and
project staff concluded that including these facilities on the sample frame
would be a costly endeavor that would produce little if any "pay-off" in terms
of identifying eligible ALFs.

In addition to the eligibility criteria based on population served
(i.e., elderly) and size (i.e., >10 beds), the facility had to describe or
represent itself as being an assisted living facility or it had to be a place
that offered at least a basic level of services. Those services were:

24-hour staff oversight

Housekeeping

At least 2 meals a day, and

Personal assistance, defined as help with at least two of the
following: medications, bathing, or dressing.

The next project task was to select a sample of FSUs. As noted earlier,
this involved a two-stage enumeration and screening process. First, staff
developed a nationwide, county-level sampling frame that estimated the relative
distribution of study-eligible facilities across the 3,141 counties and county
equivalents that are listed in the 1990 Census. Staff did this in order to
focus the sample of FSUs in counties with the highest concentrations of ALFs so
that the project would be able to obtain a sufficient sample for all phases of
the data collection.

Project staff initially considered the use of county size measures based
on the population aged 65 or older in selecting FSUs. This was based on the
assumption that the number of ALFs serving the frail elderly in a geographic
area would be proportional to the number of older persons. However, the
available evidence about development and construction indicated that the
industry was expanding at different rates in different states (e.g., ALFA,
1996; Mollica and Snow, 1996). If the distribution of ALFs did not match the
distribution of older persons, project staff could expect that this method of
selecting FSUs would concentrate the sample in states with high numbers of
elderly but few ALFs.

Selection of the FSUs. In order to increase the efficiency of the
sample, project staff created an initial national listing of places
thought to be eligible for the study in all 3,141 counties (or county
equivalents) across the country. The sources were the unduplicated listing of a
national retirement directory (DRF, 1995) that reported having listings from
licensing agencies in all 50 states and three national associations that had
members who identified themselves as assisted living facilities. (It is
important to note that the primary purpose of this activity was to focus the
sample in counties with concentrations of ALFs not to enumerate the entire
population of ALFs.) Based on this 1995 listing of more than 17,000 places in
all counties, project staff selected 60 FSUs, giving a somewhat higher
probability of selection to those counties with higher concentrations of
candidate facilities.

As expected, the FSUs identified by the process differed from those that
would have been selected based only on the proportion of the population aged 65
and older. For example, without this initial enumeration process at the
national level, the sample of FSUs would have been more heavily concentrated in
states like Texas, Ohio and Illinois, which had few ALFs compared to relatively
high numbers of older persons. Instead, FSUs in states like Pennsylvania,
California or Oregon, which had a large number of ALFs relative to their older
population, had higher selection probabilities.

The 60 FSUs were randomly selected, with higher selection probabilities
for those FSUs containing large numbers of "expected" assisted living
facilities. These FSUs contained 1,086 counties in 34 states. They also
contained 40 percent of the U.S. population aged 65 and older and 43 percent of
the initial sample frame of "expected" assisted living facilities.

2.2.1.1.2 Source of Listings of Candidate
ALFs

The next task, which was completed in September, 1997, was to create a
comprehensive list of candidate ALFs in each of the 60 FSUs. This involved the
collection of multiple lists of places that described themselves as assisted
living facilities and other places that appeared to meet the study's
eligibility criteria. For each FSU, project staff obtained data from the
following:

ALFA's 1997 list of members

The AHCA 1997 list of assisted living members

AAHSA's 1997 list of assisted living members

The 1997 HCIA Directory of Retirement Facilities (DRF,
1997)

State licensure agency lists for 1997 for all types of residential
care facilities that have 11 or more beds

Listings and advertisements from telephone book "yellow"
pages

State directories of local ALFA members, in those states in which
the state affiliate of ALFA had one, and

After collecting these multiple lists, project staff spent considerable
effort making sure they were in one of the 60 FSUs20 and creating an unduplicated list. Creating
an unduplicated list was particularly complex because of the large number of
multi-facility systems and the large number of facilities at the same address
on campuses that housed several different levels of care. In addition, staff
found high prevalence of multi-level settings that housed two or more places
that met the eligibility criteria.21

Eliminating Known Ineligibles From the Sampling Frame.
Prior to creating a sample frame, project staff excluded some places from the
unduplicated listing generated from the sources mentioned above. For example,
based on the definition provided by the HCIA Directory of Retirement Facilities
(DRF), project staff included places listed under the category "assisted
living/residential care" and places listed as "congregate living". On the other
hand, places listed by the DRF only as "independent living" were excluded from
the sampling frame of candidates because the DRF definition made it clear that
they did not: (1) describe themselves as assisted living nor (2) provide the
basic level of staffing and services required. However, if another source
(e.g., licensure list or association membership list) listed an "independent
living" facility as a potential candidate for the study, it was included on the
sampling frame. As a result, there were still a large number of facilities on
the second-stage sampling frame that identified themselves as "independent
living." As expected, the subsequent telephone survey revealed that few met the
study's eligibility criteria (e.g., did not provide 24-hour staff and help with
at least two of the following: medications, bathing, or dressing).

Among the 18,298 places on the combined list of
candidates:

7,578 (41%) were ineligible because of
size

Among the remaining 10,720
candidates:

70% appeared on only one source
listing

19% appeared on two source
listings

11% appeared on three or more source
listings

Small facilities were more likely to
appear on only one source list (e.g., 86% of the small facilities were on only
one list), while about half of the larger facilities appeared in two or more
source listings

Utility of sources:

63% of the candidates appeared on the
DRF (but many ineligibles also appeared)

46% of the candidates appeared on the
state licensure lists

Size of facilities on master list: of
candidate ALFs:

39% had 11-50 beds

23% had 51 or more
beds

From all these sources, for the 60 FSUs, a total of 18,298 candidate
facilities were listed. Project staff then eliminated known ineligibles based
on size. Information on size was missing from many lists (e.g., ALFA and other
membership lists); however, size of each facility was present for almost all of
the candidates (i.e., 97%) on the state licensure lists. Thus, at the start,
size was unknown for 4,204 facilities (23%) on the list. For facilities for
which size was known, small homes (i.e., 2-10 beds) were deemed ineligible and
removed from the master list. Project staff found that among the 18,298
candidates 7,578 places (41%) were ineligible because they had 10 or fewer
beds. The degree to which such small facilities might otherwise have met study
criteria (e.g., be a self-described assisted living facility or provide the
required services) is unknown. However, as noted earlier, prior studies found
that small facilities tend to have a younger resident population and to provide
supervision but less hands-on assistance with ADLs than larger facilities
(Dittmar and Smith, 1983; Hawes et al., 1995; Wildfire et al., 1995; Sherwood,
Mor and Gutkin, 1981; Sherwood and Seltzer, 1981).

Selecting The Sample For The Telephone Screening and
Survey. The next task was to select a sample of facilities from the
remaining 10,720 candidates on the combined listing (e.g., after eliminating
the 7,578 places with 10 or fewer beds).

In selecting the sample to be screened by telephone, project staff
oversampled the larger facilities (>51 beds) in order to increase the
likelihood of encountering ALFs offering a high level of services. This was
based on an earlier study of residential care which found that larger
facilities were more likely to have nurse staffing and to offer more services
(Hawes et al., 1995a,1995b). Thus, project staff's assumption at this stage was
that larger facilities would have greater capacity to offer more services.
Further, this approach would improve the sampling efficiency at later stages
(i.e., when the resident sample was selected, since most residents lived in
large ALFs). This oversampling did not affect final estimates about the
prevalence of various types of ALFs (including various sizes), since data were
weighted to account for the oversampling.22

2.3 DATA COLLECTION

The administrators (or their designees) in 2,945 facilities were
interviewed by telephone to determine facility eligibility for the study. The
telephone survey was conducted by Research Triangle Institute (RTI) during the
period of January March, 1998. RTI used computer-assisted telephone interviews
(CATI) for this task. The respondent was the administrator (or in his/her
absence, the assistant administrator or resident care director). (A copy of the
questionnaire appears in Appendix A.)

First, the interviewer had to determine whether the sample facility was
on a multi-level campus that contained several distinct levels of care or
residential settings (e.g., assisted living, congregate care, nursing home). If
it was on a multi-level campus, then the questionnaire was automatically routed
by the CATI program to a set of questions aimed at determining what those
levels were and whether any of the multiple units or divisions were eligible
for the study. This process was also intended to ensure that the responses
(e.g., bed size, accommodation type, services offered) were specific to each
single unit or residential setting.

Next, in the questionnaires for both the settings on multi-level
campuses and for free-standing facilities, there was a set of questions
intended to determine whether the sample facility was eligible for the study.
If the facility was determined to be eligible, then the respondent was asked a
series of additional questions that took about 10 minutes. The topics covered
included:

Size, occupancy rate, and length of time in business

Price

Type of accommodations

Nurse staffing, services offered and whether arranged or provided,
and

Admission and retention policies.

Exhibit 2 displays the results of the telephone
screening for eligibility, the reasons for ineligibility of the listed
candidates, and the response rates. As shown, the most striking finding was the
rate of ineligibility.23 The listings on the sample frame, as noted
earlier, were from multiple sources that most observers presumed were reliable
sources or identifiers of assisted living facilities. It is also worth noting
that the source of the largest number of valid listings, the DRF, was also the
source of the largest number of ineligibles. This demonstrates the difficulty
involved in determining how many assisted living facilities are currently in
operation and in identifying those facilities, given varying definitions and
criteria across our sources of listings, across states, and across facilities
themselves. It may also help explain why some estimates of the total supply of
assisted living facilities are quite high, as discussed in the next
section.

2. Not
interviewed (multiple call-backs but no completion, language
barrier)

(2.4%)

Non-Responding Ineligibles--Unable to Contact
(no telephone number, out-of-order, or no answer after at least 10
calls)*

(6.2%)

TOTAL

100%

*The places listed as "unable to
contact" were also assumed to be ineligible. First, project staff used multiple
sources, including "white" and "yellow-page" telephone listings, retirement
directory listings, local information, and so on, to secure telephone numbers.
We assumed that an eligible ALF would have a listed number if it were still in
business. Second, project staff made at least 10 telephone calls during
business hours to each place. We assumed that if the place was an eligible ALF,
there would have been staff on duty 24 hours per day and someone would have
answered at least one of >10 telephone calls at various times of the
day. Thus the total number of ineligibles was estimated as 46% (i.3., 41 +
6.2).

The reasons for ineligibility are also interesting. At the first level
of "cleaning" the list of candidate facilities, staff eliminated a large number
of small facilities (i.e., more than 40% of the originally compiled list). This
effort was apparently fairly successfully, since only 10 percent of the
remaining sample were ruled out because of size. However, a total of 25 percent
of the facilities on the sample frame (i.e., the "independent living"
facilities and other ineligibles) were ruled out because they offered few
services and little, if any, personal assistance (e.g., help with medications,
bathing, dressing).24
Most observers would agree that such facilities should not be regarded as
"assisted living." Finally, staff concluded that an additional 12 percent of
the listings were ineligible. These miscellaneous reasons for ineligibility
were because the facility was closed or was something other than an eligible
facility (e.g., was a convent or a licensed nursing home) (5.8%) or the
facility fell into the category "unable to contact" (6.2%) (See
footnote 23).

2.4 ANALYTIC METHODS

For most of the analysis, this report presents descriptive statistics
for individual variables, such as the mean for interval indicators and
percentages for categorical measures. Project staff utilized t
statistics for comparisons between two groups (e.g., self-described ALFs and
other facilities). For comparisons among more than two categories (e.g., the
combination of different levels of service and privacy), regression equations
were estimated that allowed the research team to compare the overall sample
mean for all facilities with the mean for facilities in each category and to
test the statistical significance of any difference.

All of the analyses were carried out on data weighted to represent the
assisted living industry in the nation as a whole. SUDAAN, a statistical
software package that provides appropriate variance estimates for clustered
data derived from multi-stage samples, was used for all analyses.

Despite the enormous interest and enthusiasm generated by the philosophy
of assisted living and its rapid growth in this country, there is little
definitive data available on the number and characteristics of facilities and
residents. While there have been a number of studies, particularly surveys
sponsored by national trade associations, they have been limited by two
factors.

First, many prior studies of assisted living facilities have focused on
the industry in only a few states (personal communications from Kane; Newcomer;
Zimmerman and Sloane). Second, most of the national surveys have been conducted
by industry trade associations and have not selected the facilities from a
nationally representative sample (e.g., ALFA, 1998; Gulyas, 1997; Hodlewsky,
1998). The lack of a national listing of facilities, the limitations of state
licensure lists, given the variability in licensure policy and definitions, and
the potential bias introduced from surveying only trade association members
have hindered attempts to describe the assisted living industry and to
understand its role in meeting the needs of frail elders. Third, the existing
national surveys of facilities have been limited by somewhat low response rates
among the facilities surveyed.25 As a result, the available data cannot be
regarded as representative. Thus, there are no definitive data generalizable to
the nation as a whole that describe the assisted living industry.

In early 1998, there were an estimated 11,459 assisted living
facilities in the U.S. that:

Served the elderly

Had more that 10 beds

And

Identified themselves as assisted
living

Or

Provided 24-hour staff, >2
meals per day, housekeeping, and help with at least two of the following:
medications, bathing, and dressing.

The ASPE study fills that void with empirical data drawn from a survey
of a nationally representative sample of assisted living facilities and a
response rate of better than 84 percent. The sections that follow provide data
on the size and characteristics of the assisted living industry in the United
States.

3.1 SIZE OF THE INDUSTRY

As noted earlier, there is general agreement that assisted living is the
most rapidly growing type of senior housing in the United States. There is less
agreement, however, on the size of the current supply of assisted living
facilities. In 1998, for example, estimates of the number of facilities ranged
from a total of about 27,000 facilities to more than 40,000 ALFs (Mollica,
1998; ALFA, 1998; Hodlewsky, 1998). Estimates of the number of beds ranged from
about 350,000 to more than one million (Citro and Hermanson, 1999; Mullen,
1997; ALFA, 1998; Hodlewsky, 1998). Thus, one of the key objectives of the ASPE
study was to determine the size of the current supply of assisted living.

The data presented in this report are national estimates
based on the survey of the nationally representative sample of assisted living
facilities.

As shown in Exhibit 3, estimates based on the
telephone survey of administrators indicated that in early 1998, there were
11,459 facilities and 611,300 beds that met the definition of assisted living
that was embodied in the study's eligibility criteria.26

In comparison to other estimates about the assisted living industry, the
ASPE study estimate is considerably lower than those of provider organizations,
such as ALFA. However, there are several reasons for believing the ASPE study
represents an accurate estimate of the number of ALFs that met study
eligibility as of early 1998.

First, this study's estimates are the product of an extensive attempt to
secure a comprehensive list of all possible eligible facilities. Second, they
are based on a national probability sample of facilities, unlike other studies.
Third, it involved a systematic effort to determine whether the places
believed to be assisted living or "called" assisted living met a
commonly accepted definition of "assisted living." In particular, the ASPE
study made a concerted effort to exclude facilities on the list of candidate
ALFs that in reality provided few services or did not offer meaningful personal
assistance to residents.27 Fourth, as noted, the ASPE study excluded
small facilities (i.e., 2-10 beds). Exhibit 4 displays
the distribution of the candidate facilities that were provided to project
staff on various lists and represented as being ALFs. As shown, the majority of
facilities on those lists did not meet study eligibility criteria. Finally, the
survey results and estimates are based on very high participation rates among
the sampled facilities. These features of the ASPE study have helped overcome
limitations in other studies that estimated the supply of assisted living
facilities as being much larger.

3.2 GENERAL CHARACTERISTICS OF THE INDUSTRY

As shown in Exhibit 5, the majority of
facilities (72%) that met study eligibility criteria described themselves as
assisted living facilities or advertised that they provided assisted living
services. However, more than one-quarter (28%) of the facilities that met study
eligibility criteria did not hold themselves out as being "assisted living,"
even though they provided the same type of care and services as places calling
themselves "assisted living."28 In part, this may be a product of state
licensure regulations. For example, in Wisconsin, assisted living facilities
are termed residential care apartment complexes or community-based residential
care facilities (Mollica, 1998).

ALFs ranged in size from 11 beds to more than 1500. The average facility
had 53 beds (in rooms or apartments) with a median of 48 beds. Most ALFs (67%)
had between 11 and 50 beds, as displayed in Exhibit 6.
Twenty-one percent of the ALFs had 51-100 beds, while 12 percent had more than
100 beds.

While most facilities were in the range of 11 to 50 beds, two-thirds
(67%) of the residents -- were in the larger facilities (i.e., >50 beds).
This was consistent with ASPE's earlier study of board and care homes that
found most residents lived in larger facilities, even though two-thirds of the
homes were very small (i.e., 2-10 beds) (Hawes et al., 1995).

The average occupancy was an estimated 84 percent nationwide.

3.2.2 Affiliation

Another feature of facilities was their affiliation. The administrators
reported that the majority of facilities were free-standing (55%); however, a
sizeable proportion of ALFs (45%) were located on multi-level campuses that
housed other types of residential settings or multiple levels of care. An
estimated 5,220 facilities were located on such multi-level campuses at the
start of 1998.

Exhibit 7 displays the main types of residential
care settings found on multi-level campuses. Some multi-level campuses housed
several different types of residential settings (e.g., nursing home, assisted
living, congregate or independent living).29 Other multi-level campuses housed only an
assisted living facility and a nursing home. In fact, a campus with a nursing
home and an eligible "assisted living" facility was the most common
configuration on multi-level campuses. In addition, the administrators of ALFs
located on a multi-level campus were asked whether there was any kind of SCU on
campus.30 As shown in
Exhibit 7, five percent of the administrators reported
that the ALF was located on a campus with an SCU that was part of a licensed
nursing home. Six percent reported that an SCU providing residential care or
assisted living was located on the campus.

The assisted living industry also displayed considerable variation in
terms of the length of time the facilities had been in business as of early
1998. The average was 15 years, but there was a wide range around that. As
shown in Exhibit 8, almost one-third (32%) of the
facilities had been in business for five or fewer years as of early 1998. More
than half (58%) of the facilities eligible for the study had been in business
for a decade or less. Thus, while many facilities (19%) had been providing
residential care with supportive services for more than 20 years, the majority
ALFs started in business during the preceding decade.

For many advocates of assisted living, environmental characteristics are
considered one of the most important features that distinguish assisted living
from nursing homes and other types of residential care facilities. As noted
earlier, privacy and consumer choice are key elements of the philosophy of
assisted living in the view of both consumer and provider groups (Assisted
Living Quality Coalition, 1998). Moreover, individual and focus group
interviews with consumers found that they overwhelmingly preferred to reside in
private rooms or apartments (Jenkens, 1997; Kane et al., 1998). Thus, the
nature of the environment, that is the accommodations, is a key component of
assisted living.

82% of all respondents in one survey indicated their
preference for a private room or apartment in assisted living.

Despite widespread consensus among residents about their preferences,
there is disagreement within the industry about the environmental features that
are essential for a place to be defined as an "assisted living facility,"
particularly about whether private rooms or apartments and kitchens were
essential features. In addition, there is disagreement among policymakers about
whether privacy and apartments are key features of a place that can be licensed
or reimbursed under Medicaid waivers as "assisted living" (Mollica, 1998).

4.1 PRIVACY

Privacy31 and
consumer control of the environment encompass a variety of concepts and
features of the environment, facility policies, and staff behavior. Typically,
these are defined in terms of such policies or features as the ability of
residents to lock their doors; control the temperature in their units; or have
pets. Autonomy, however, can also include other features, such as whether the
resident can control arrangement of furniture, whether staff knock on doors
before entering, and so on. These multi-facted aspects of environmental
autonomy and control will be addressed in a forthcoming report.32 The initial telephone survey
concentrated only on whether units were shared or private.

Privacy is typically defined as a unit (room or apartment)
that is not shared except with a related individual.

As noted above, there is ample evidence that consumers prefer private
living units. In one study, 82 percent of the elderly respondents indicated
their preference for a private room or apartment in assisted living. Only four
percent indicated a preference for sharing their accommodations with an
unrelated person (Jenkens, 1997). In another study, 94 percent of the residents
of assisted living facilities who were interviewed indicated that a private
room and bath were important features and that they considered such private
accommodations essential to maintaining their independence and dignity (Kane et
al., 1998).

Despite the widespread agreement among consumers about the importance of
privacy, the supply of places calling themselves assisted living did not
uniformly meet this preference. As shown in Exhibit 9,
the majority of facilities (73%) had some shared bedrooms (in a room or
apartment unit).33 Only
27 percent of the assisted living facilities nationwide had all-private units.
While this arrangement may not meet the general preferences of consumers, it
did allow consumers choice about accommodations and may have made assisted
living affordable for moderate- and low-income seniors.

4.1.1 Privacy at The Facility Level: Categorization Of Facilities

Because state policy had not reached a consensus about the environmental
features that are an essential component of assisted living, one goal of the
study was to examine the effect of different levels of privacy and services. In
order to describe the assisted living industry more systematically and to
facilitate comparisons among ALFs, facilities were classified according to the
level of privacy they offered.

High Privacy. Initially, project staff defined high privacy
facilities as only those in which all units (rooms or apartments)34 were private. However, members
of industry trade associations argued that many facilities offered a few shared
units to meet the needs and preferences of some residents. Thus, a high privacy
facility was defined as one in which 80 to 100 percent of the units were
private. As shown in Exhibit 9, all units were private
in only 27 percent of the ALFs. Allowing up to 20 percent of the units to be
shared raised the proportion of ALFs in the "high privacy" category to 31
percent, as displayed in Exhibit 10.

Low Privacy. Any ALF that had no bedrooms shared by three or more
unrelated persons but in which fewer than 80 percent of the bedrooms were
private was defined as low privacy. As shown in Exhibit
10, 40 percent of all the assisted living facilities were categorized as
offering a "low privacy" setting.

Minimal Privacy. Any facility that housed three or more unrelated
individuals in the same bedroom (whether in a room or apartment) was defined as
providing minimal privacy. Such a room, referred to as a "ward-type bedroom,"
was considered incompatible with the concept of assisted living. Thus, any
facility with such rooms was defined as providing "minimal privacy" regardless
of the characteristics of their other units. As shown in Exhibit 10, more than a quarter of all facilities had at
least one bedroom that housed three or more residents.

The proportion of facilities that offered low or minimal privacy seemed
large for an industry in which one of the chief philosophical tenets is
"privacy." To examine this issue more carefully, comparisons were made between
two groups of facilities that met study eligibility criteria. The two groups
were: (1) those that defined or identified themselves as an "assisted living
facility" (a "self-described" ALF) and (2) those that did not call themselves
"assisted living" but met specified criteria related to availability of
services (the "other " ALFs).

As shown in Exhibit 11, facilities offering
"minimal privacy" were less common among self-described ALFs (26%) than among
the "other" ALFs (34%). Similarly, high privacy facilities were more common
among self-described ALFs (34%) than among the "other" ALFs (23%). Despite the
fact that self-described ALFs were more likely to offer high privacy than
"other" ALFs, the proportion of self-identified ALFs with low privacy (40%) or
minimal privacy (26%) was still substantial. At the same time, the fact that
more than two-thirds of self-identified ALFs (70%) offered consumers both
private and semi-private accommodations can be viewed as offering consumers a
greater range of choices.

Facility-level distributions indicated significant variability among the
industry. However, an examination of the actual distribution of units provides
a more accurate picture of privacy from the resident's perspective. While most
facilities offered shared units (either rooms or apartments), as shown in
Exhibit 12, an estimated three-quarters of the units
(73%) across all ALFs were private. Only an estimated one-quarter (25%) were
semi-private rooms or apartments. Only two percent of the units were
"ward-type" rooms shared by three or more unrelated individuals. The reports by
administrators demonstrated that while the majority of ALFs offered some
semi-private units, the industry as a whole recognized consumers' preferences
for privacy.35

There was somewhat less privacy for residents with respect to bathrooms.
Administrators reported that only 62 percent of all resident units had private
full bathrooms (i.e., toilet, sink and bathtub or shower), as shown in
Exhibit 13. An additional five percent of all units
had a private "half" bath (i.e., toilet and sink); however, residents had to
share bathing facilities. Further, a third (33%) of all units in ALFs required
the resident to share a full bathroom, including the toilet, sink and bathing
facilities (i.e., tub or shower). Thus, a total of 38 percent of the resident
units involved sharing all or part of bathroom facilities.

4.2 ACCOMMODATIONS

The survey also asked administrators about the types of rooms or
apartments offered and the bathrooms available to residents.

4.2.1 Resident Units: The Mix of Rooms and Apartments

As noted earlier, no model of regulation at the state level has emerged
to define the essential characteristics of assisted living. The earliest
legislative model, which was in Oregon, however, defined a model of assisted
living that required resident accommodations or units to be apartments and
generally mandated privacy for both bedrooms and bathrooms.36 However, this initial
environmental model has not been universally adopted across the United States.

As Mollica (1998) noted, states have treated assisted living very
differently in their regulations. One type of state policy essentially treated
assisted living as a new model of residential long-term care that required
apartments. Another state model viewed assisted living as a service rather than
a particular environmental configuration and allowed that service to be
provided in a variety of settings. A third type of state approach used the term
"assisted living" for a licensure category that incorporated the state's
generic board and care facilities and thus did not differentiate assisted
living in terms of setting or services. As a result, in most states a variety
of places may call themselves assisted living, regardless of the type of
accommodations they offer. At the time of the ASPE study survey, 30 states that
had established or proposed assisted living policy. Apartment units were
required in only half of these states either through licensure rules or
Medicaid payment policy for ALFs participating in waiver programs (Mollica,
1998).

As a result of both state policy and choices by owners and operators,
there was considerable variability among facilities and the type of units they
offered. As shown in Exhibit 14, the majority of ALFs
(68%) did not offer any apartment accommodations; they offered only rooms. An
estimated one-quarter of the ALFs (26%) offered only apartments. Relatively few
ALFs (6%) offered a mix of rooms and apartments.

For residents, the most common accommodation was in a room (57%), as
displayed in Exhibit 15. An estimated 43 percent of
all resident units were apartments.37

EXHIBIT 15. Distribution of Resident
Units Between Rooms and Apartments

4.2.2 Resident Room and Apartment Types

As reported above, most resident units were rooms rather than
apartments. According to the administrators, the most common type of room was a
single occupancy bedroom with a private full bathroom. As shown in
Exhibit 16, this type of resident unit accounted for
42 percent of all resident rooms and was the most common type of resident
accommodation.

* The "other room type" included a
variety of arrangements and was excluded from the estimation of private
rooms.

As shown in Exhibit 17, the two most common
apartment types were one bedroom, single occupancy apartments (41% of all
apartment units) and single occupancy studio apartments (32% of all apartment
units).38

It is also interesting to note that most of the apartment units were
private.39 Only 21
percent of the apartments were shared with an unrelated individual. By
contrast, at least 43 percent of the rooms were shared.

The services a facility provides have generally been determined by
internal policies related to the types of residents the facility wants to serve
and its pricing structure (Manard, 1997). They may also be affected by state
licensure regulations. In 1997, most states did not list a specific set of
services or staffing that were required; however, many states indirectly
affected services by specifying admission and retention criteria for assisted
living or residential care facilities (Mollica, 1998). However, over the last
decade, studies found that many states were expanding both the types of
residents that assisted living and residential care facilities could admit and
retain and the level of care and services that could be provided in such
facilities (Hawes, Wildfire and Lux, 1993; Mollica, 1998). Thus, states and
facilities differed about both the types of services and staffing that would be
available and about whether the facility could provide the services directly or
had to arrange for the provision of services with an external provider, such as
a home health agency.

The survey explored differences in staffing and service arrangements for
several reasons. As noted earlier, one of the key philosophical principles of
assisted living is that the facility will, as defined by ALFA (1998), ensure
that "supportive services are available, 24 hours a day, to meet scheduled and
unscheduled needs." Given this, one of the key questions for this research was
whether the industry provided the range of services needed to meet the
scheduled and unscheduled needs of residents. In addition, facilities' service
arrangements were of interest for several other reasons. For example, whether
services were provided by ALF staff or arranged through an outside provider
might affect the admission and retention policies of facilities and thus the
ability of residents to age in place. Further, these arrangements could affect
the continuity of care, as well as the cost of care and who bears the cost.
Finally, the degree to which assisted living could substitute for nursing home
care was of interest to policymakers, and that capacity may be affected by
staffing and service arrangements.

While addressing each of the issues listed above is beyond the scope of
this study, at the least, the study is designed to describe the variety of
arrangements found in ALFs across the country. This section of the report
describes the variations in nurse staffing and service availability.

5.1 SERVICE AVAILABILITY

As shown in Exhibit 18, nearly all facilities
provided or arranged 24-hour staff, housekeeping, and three meals per day.
Moreover, more than 90 percent of the facilities also provided or arranged
medication reminders or assistance and help with bathing and dressing, and 87
percent of the ALFs offered central storage of or assistance with medications.
Finally, most of the facilities that offered these services provided them with
facility staff. However, it is interesting to note that between seven and nine
percent of the ALFs arranged for these services through an external agency or
provider.

The picture of service availability changed for care or monitoring by
any licensed nurse, which included Registered Nurses (RNs) and Licensed
Vocational Nurses (LVNs) or Licensed Practical Nurses (LPNs). As shown in
Exhibit 18, one out of five facilities (21%) did not
offer any care or monitoring by a licensed nurse.

Among the facilities that did offer some nursing care, about two-thirds
provided the service with facility staff, while one-third arranged nursing
services only through an external provider, such as a home health agency.
Still, a significant majority (79%) of assisted living facilities reported they
would provide or arrange needed nursing care by an RN or LPN.

Therapy services were the least frequently offered service and the one
most commonly arranged through an outside agency. One quarter of the facilities
(26%)did not offer therapy services. Only 12 percent offered therapy services
with facility staff, while the majority (60%) would arrange the provision of
therapy through an external agency.

5.2 NURSE STAFFING

The administrators were also interviewed about the facility's staffing
pattern with respect to licensed nurses. Assisted living was developed on a
social model; however, as NCAL argued, "nursing and other health-related
services are playing an increasingly large role in the industry" (Hodlewsky,
1998). This is because of a variety of factors, including the basic philosophy
of assisted living and factors that are expected to contribute to increased
acuity among residents (Manard and Cameron, 1997; Mollica, 1998).

As shown in Exhibit 19, more than half (55%) of
the ALFs reported having an RN on staff either full or part- time (i.e., 40
hours a week or less). Only 40 percent had a full-time RN on staff. Further,
nearly three-quarters of all ALFs (71%) had a licensed nurse (RN or LPN/LVN) on
duty full- or part-time in the facility. By contrast, a 1993 study of
traditional board and care homes in 10 states estimated that only 21 percent of
the facilities had a licensed nurse on staff full- or part-time ((Hawes et al.,
1995a).

The survey of administrators also asked about whether the facility would
provide nursing care, and the results indicated that not all ALFs with a nurse
on staff would provide nursing care with their own staff. As displayed in
Exhibit 20, slightly more than half (54%) of the ALFs
reported that they would provide some nursing services with their own staff or
with their own staff in combination with outside staff. Another quarter (25%)
of the ALF administrators reported that they would arrange for nursing care
with an outside provider, such as a home health agency. However, a substantial
proportion of ALFs (21%) would neither provide nor arrange care or monitoring
by a licensed nurse.

EXHIBIT 20. Facility Practice on
Availability of Services by RN or LPN

A combination of facility policies and state regulations govern the
admission and discharge criteria used by assisted living facilities. Some
policies, such as the amount of nursing care a resident may receive in a
residential care setting other than a nursing home, may be defined by state
regulations. Other admission and retention criteria are more clearly a product
of facility decisions alone in most states. For example, the decision about
whether to accept and retain residents with behavioral symptoms, such as
wandering, is typically set by the facility alone. Further, while state
regulations may set parameters for admission and retention policies, ALFs are
nearly always free to set their own policies within these overall constraints.

Admission and retention policies, whatever their origin, can have
widespread effects on both consumers and providers of long-term care services.
First, they affect who may enter and receive care in an assisted living
facility. Second, admission and retention policies will have an impact on the
ability of residents to "age in place," once they have moved to an ALF. Third,
they affect the ability of ALFs to substitute for nursing home care. As such,
admission and retention policies can be expected to affect not only residents
but also the nature and, potentially, the financial viability of at least two
segments of the health and long-term care sector assisted living facilities and
nursing homes. Further, they may indirectly affect the board and care sector,
as well as other forms of housing with supportive services. Thus, gathering
data that described the admission and retention policies of a national
probability sample of ALFs was a central focus of the survey.

6.1 ADMISSION AND RETENTION POLICIES

ALF administrators were asked whether they would admit or retain a
resident who had a particular condition or service need. Exhibit 21 displays national estimates about the
admission and discharge policies in place for assisted living facilities, based
on responses from the administrators. As shown, admission and discharge
policies were essentially the same. Generally, facilities would admit the same
types of residents they were willing and able to retain.40

The policies on admission and retention reported by administrators
raised questions about whether assisted living facilities could reasonably meet
their philosophical commitment to enabling residents to age in place. One
example can be seen in policies related to changes in residents' physical
functioning. More than two-thirds of the ALF administrators (71%) reported they
would admit a resident who used a wheelchair, and 62 percent reported they
would admit and retain residents who needed assistance with locomotion (i.e.,
walking or using a wheelchair). However, fewer than half would retain (46%) a
resident who needed help with transfers (e.g., from bed to a chair or
wheelchair or to standing). Similarly, nearly two in five ALFs (37%) would not
retain a resident with urinary incontinence.41

Facility policies on retention of residents who needed nursing care also
raised questions about the ability of ALFs to meet residents' unscheduled needs
and represented another limitation on residents' ability to age in place. Most
facilities (82%) were willing to accept or retain a resident who required
temporary nursing care or monitoring. However, only slightly more than
one-quarter of the ALFs (28%) reported being willing to retain residents who
needed nursing care or monitoring for more than 14 days. These policies raise
the question of whether such facilities can be regarded as able to meet
residents' unscheduled needs and certainly limited their ability to allow
residents to age in place. Indeed, focus group interviews with residents of
assisted living facilities revealed that many residents were dissatisfied with
being discharged to a hospital or nursing home whenever they needed any daily
nursing care or monitoring (Hawes and Greene, 1998).

Finally, many facilities had restrictive policies on admission and
retention of residents with cognitive impairment.42 These policies raised questions about the
general role of ALFs in meeting the long-term care needs of the elderly and
disabled. Further, the retention policies related to conditions common among
persons with Alzheimer's disease or other dementias represented a potentially
very significant limitation on the ability of many residents to age in place.
As shown in Exhibit 21, fewer than half the
administrators reported that they were willing to admit (47%) or retain (45%)
residents with moderate to severe cognitive impairment. Similarly, only about
one-quarter of facilities reported that they were willing to admit (28%) or
retain (24%) residents with behavioral symptoms, such as wandering, physical or
verbal aggression, or socially inappropriate behavior. Such admission and
discharge policies limit the ability of many assisted living facilities to
provide care for individuals with Alzheimer's disease and other types of
dementia. They also limit the ability of those ALFs to enable such residents to
age in place.

ALF admission and discharge policies also affect the degree to which
ALFs could reasonably be regarded as a substitute for nursing homes. Nursing
homes regularly provide care for individuals with moderate and severe cognitive
impairment, as well as individuals with behavior problems, and they provide
daily nursing care and monitoring as a matter of course. While some ALFs
appeared willing to retain residents who would be eligible for nursing home
care, the majority of ALFs were not. Moreover, the ability of ALFs to provide
appropriate care for such persons is unknown.

6.2 RESIDENT CHARACTERISTICS

Part of this project involves in-person interviews with a national
probability sample of approximately 1,500 residents of assisted living
facilities across the country. Analysis and reporting of these data are
forthcoming and will provide the most accurate picture of the characteristics
of residents in assisted living facilities. However, in the telephone
interviews reported here, administrators were asked to estimate the proportion
of their residents who had moderate to severe cognitive impairment and the
proportion of "heavy care" residents.

Heavy Care Residents were defined as residents who,
during the preceding 7 days, received hands-on assistance with one or more of
the following ADLs: locomotion, transfers, toileting or eating. As shown in
Exhibit 22, administrators estimated that 24 percent
of the residents had such limitations in ADLs during the seven days prior to
the interview date.

Moderate to Severe Cognitive Impairment was defined
as problems with short-term memory, orientation to time, place and person, and
impaired judgment or cognitive skills for daily decision making. ALF
administrators estimated that 34 percent of the residents were cognitively
impaired.

If accurate, these estimates by assisted living facility administrators
help place in context the role of assisted living in meeting the needs of the
elderly and disabled who need residential long-term care. There appears to be
some overlap of residents across all three settings, if one considers only
physical functioning in ADLs and cognitive status. However, the administrators'
estimates suggest that ALFs, on average, had a resident case mix that was
slightly less impaired in terms of cognitive status than that of traditional
board and care homes. On the other hand, ALF residents appeared to be more
impaired than board and care home residents, on average, in terms of
limitations in physical functioning. The ALF residents, however, were estimated
to be significantly less impaired than most nursing home residents, as
displayed in Exhibit 22.43

6.3 RESIDENT DISCHARGES

We also asked facilities about whether any residents had been discharged
during the preceding six months because they needed nursing care. Nearly
three-quarters of the facilities (72%) reported that one or more residents had
been discharged because the resident needed skilled nursing care.

As noted earlier, prior studies have suggested considerable variability
among ALFs (Gulyas, 1997; Hodlewsky, 1998; Manard et al., 1992) and among
states in the laws and regulations that governed assisted living facilities
(Mollica, 1998). Thus, one focus of the analysis of the data reported by
administrators was on the differences and similarities among ALFs. Several
different types of assisted living facilities were identified and are examined
in this section of the report.

First, as noted earlier, two types of facilities were included in
this study. One group described or represented themselves as an "assisted
living" facility. The other group did not hold themselves out as ALFs but
nevertheless met eligibility criteria for the study, in particular by offering
a specified range of services thought to be consistent with "assisted living."
Thus, one key comparison is between these two types of facilities.

Second, another major difference was found in the affiliation of the
ALFs. As noted earlier, most ALFs were free-standing, that is ALFs operating on
a campus with no other affiliated facility. However, a sizeable number of ALFs
were located on a multi-level campus, that is, on a campus that encompassed
other health or housing settings. This section of the report also examines the
differences and similarities between these two types of ALFs.

Finally, one key analytic goal of the study is to examine the effect
of differences among ALFs in the services and environment they provide. Thus,
as an initial part of this examination, a model has been defined that
characterizes facilities by the mix of services and privacy they
provide.

One of the key comparisons was between places that described or
represented themselves as assisted living facilities (i.e., self-described
ALFs) and "other" ALFs. Other ALFs were those that called themselves by some
other name (e.g., residential care facility, adult congregate care facility)
but offered the same basic supportive long-term care services (i.e., 24-hour
staff, housekeeping, meals, assistance with >2 ADLs). As noted
earlier, nearly three-quarters (72%) of the facilities held themselves out as
being "assisted living facilities." Twenty-eight percent fell into the "other"
category.

These two types of facilities were remarkably similar on a variety of
characteristics, such as size, services provided or arranged, nurse staffing,
most of the admission and retention criteria, and the characteristics of their
residents (i.e., resident case-mix). However, self-described ALFs differed from
the other facilities on key features, as displayed in Exhibit 23.44 As shown, the self-described ALFs had lower
occupancy rates and, on average, had been in business for a shorter period of
time. Self-described ALFs were also significantly more likely to offer
apartments than the other facilities and more likely to offer private
accommodations than the other ALFs. Self-described ALFs were also more likely
to admit and retain residents who used a wheelchair and who received help with
locomotion. Further, they had somewhat higher reports of discharging residents
who needed nursing care. Finally, among facilities that had several basic
rates, depending on the services or accommodation, (i.e., multiple rate
facilities), the self-described ALFs had significantly higher monthly prices
than the facilities that did not describe themselves as "assisted living."

7.2 FREE-STANDING COMPARED TO ALFs ON A MULTI-LEVEL
CAMPUS

As noted earlier, the majority of ALFs nationwide were free-standing
(55%). However, a sizeable number (45%) were located on what are referred to as
a "multi-level campus." A multi-level campus housed more than one residential
setting and provided more than one level of care. The most common additional
levels of care were licensed nursing homes, congregate apartments, and
independent living settings.

ALFs that were free-standing and those located on a multi-level campus
were similar on such characteristics as size, length of time in business, the
percent that described themselves as assisted living facilities, and the
administrators' estimates of general resident characteristics. However, these
facilities also had a number of statistically significant differences, as
displayed in Exhibit 24. As shown, ALFs situated on a
multi-level campus had higher occupancy rates and tended, on average, to have
higher monthly prices. At the same time, they were more likely to offer private
units and to have a higher proportion of apartments, compared to single rooms.
They also tended to provide or arrange more services, most notably nursing care
and therapies. Further, they had much higher levels of nurse staffing,
including full-time staffing by RNs and full or part-time staffing by RNs and
LPNs. Not surprisingly, ALFs on multi-level campuses were also more likely to
admit and retain residents who needed nursing care. They were also more likely
to admit and retain residents who used a wheelchair. Finally, ALFs on
multi-level campuses were more likely to have discharged a resident who needed
nursing care. This could be a result of having an affiliated alternative level
of care available, such as a nursing home, to which to discharge residents.
Alternatively, it is possible that such ALFs admit or retain a higher acuity
resident mix because of the services they could offer. However, there is no
evidence, based on estimates provided by administrators on two dimensions, that
ALFs on multi-level campuses had a more intense resident case mix.

7.3 DIFFERENT MODELS OF ASSISTED LIVING

Attempts to understand assisted living and its role in providing
long-term care to the frail elderly have been hindered by the lack of a common
definition of "assisted living." Both the vagaries of the market place and
variability in state policies have contributed to a situation in which a
multiplicity of places are known as assisted living. Yet there are enormous
differences among places known "assisted living facilities." These include
differences in size, services, staffing, accommodations, and price (Gulyas,
1997; Hodlewsky, 1998; Manard and Cameron, 1997). Thus, analyzing data on
facilities and reaching conclusions about "assisted living" can involve
combining "apples and oranges," to borrow a phrase from Susan Hughes'
description of evaluations of home and community-based care (Hughes, 1985).

The data reported by administrators also revealed substantial
variability among places known as assisted living. To facilitate descriptions
and comparisons among these ALFs, project staff developed a classification that
divides the universe of assisted living facilities into four categories of
ALFs. These four models classify ALFs based on their particular mix of services
and privacy. Moreover, they represent very different conceptions of the role of
assisted living. Thus, this classification scheme can be used to provide a more
meaningful description of the universe of ALFs. It should also facilitate
examination of the effects of different arrangements on outcomes of interest,
such as resident length of stay, consumer satisfaction, affordability, and the
capacity of such facilities to serve as a viable alternative to nursing home
care.

7.3.1 Environmental Dimension

As briefly discussed in Section 4, ALFs were
classified into two categories based on the level of privacy they offered.
While privacy per se does not necessarily ensure consumer control over
their environment, the previously cited studies clearly indicate the importance
that consumers have placed on having a private room or apartment. Thus, privacy
of the resident unit was selected as one axis or dimension of the
classification. Within that, three levels of privacy were defined:

High Privacy. The initial approach was to define high privacy
facilities as those in which all resident units (rooms or apartments) were
private (i.e., not shared by unrelated individuals). However, it was also
important to recognize the importance of a facility being able to offer
consumers some choice, for example, a few shared units to meet the needs and
preferences of some residents. Thus, high privacy was defined as a facility in
which between 80 and 100 percent of the units were private. An estimated 40
percent of the ALFs were categorized as high privacy.

Minimal Privacy. A facility was categorized as "minimal
privacy" if it had one or more rooms that housed two or more unrelated
individuals in the same bedroom. Such a room, referred to as a "ward-type
bedroom," was considered incompatible with the concept of assisted living
regardless of the characteristics of their other units. An estimated 28 percent
of the ALFs were categorized as minimal privacy.

Low Privacy. Any ALF that had no bedrooms shared by three or
more persons but in which fewer than 80 percent of the bedrooms were private
was defined as low privacy (i.e., 1-79% of the units were private). An
estimated 31 percent of the ALFs were classified as low privacy.

The key analysis focused on the differences between high and low privacy
ALFs. As shown in Exhibit 25, high privacy ALFs had
higher occupancy rates, on average, and a higher basic monthly price. They were
also more likely to be located on a multi-level campus. Finally, none of the
high privacy ALFs had more than half their resident units as shared (i.e.,
semi-private). Indeed, three-quarters (75%) of the high privacy ALFs were
completely private, that is, none of the units were shared.

The most striking comparisons between high and low privacy ALFs,
however, relates to differences in their admission and retention policies. As
displayed in Exhibit 25, high privacy facilities were
significantly less willing to admit and retain residents with behavioral
symptoms, such as wandering or socially inappropriate behavior, and those with
urinary incontinence. Similarly, they were less willing to retain residents who
needed help with locomotion or who needed nursing care for 14 or more days.
Finally, high privacy facilities were less likely to provide central storage of
or assistance with medications.

7.3.2 Service Dimension

Services were another key dimension since the philosophy of assisted
living embodies the concept of aging in place and services intended to meet the
scheduled and unscheduled needs of residents. Three levels of services were
defined:

(1) High Service ALFs. A facility was classified as providing
high services if it provided at least the following:

24-hour staff oversight

Housekeeping

At least 2 meals a day

Personal assistance, defined as help with at least two of the
following: medications, bathing, or dressing

At least one full-time registered nurse (RN) on staff; and

Nursing care with facility staff.

Some observers would argue that the last two criteria were not an
essential component of assisted living. For example, one might argue that a
facility that would arrange nursing care through an external agency could also
be classified as high services and that an RN on staff was not necessary.
However, for purposes of distinguishing between ALFs, those that also have an
RN on staff and offer nursing care with their own staff do provide more
extensive services. Moreover, one could argue that providing such services
might improve the ability of the facility to appropriately supervise assistance
with medications, monitor the health status of residents, assess changes over
time, and supervise and monitor the quality of the services provided or
arranged. Further, such services might enhance residents' ability to age in
place and enable the ALF to serve as a viable alternative to nursing home care.
An estimated 31 percent of the ALFs were categorized as high service.

(2) Low Service ALFs. An ALF was classified as providing low
services if it did not have an RN on staff OR did not provide nursing
care with its own staff but did provide the following:

24-hour staff oversight

Housekeeping

At least 2 meals a day

Personal assistance, defined as help with at least two of the
following: medications, bathing, or dressing

These ALFs included both those facilities that were willing to provide
or arrange nursing care for residents but did not have an RN on staff or were
unwilling to provide nursing care with their own staff and facilities that
provided basic services but did not offer any nursing care. An estimated 65
percent of the ALFs were classified as providing low services.

(3) Minimal Service ALFs. A facility was categorized as providing
minimal services if it did not provide at least some level of personal/ADL
assistance. Essentially, this is the level of services typically associated
with congregate or domiciliary care, that is, basic room and board plus
oversight. Such services would include: 24-hour staff oversight, housekeeping,
and meals. However, the facility did not offer personal
assistance with at least two of the following: medications, bathing, or
dressing. Only an estimated four percent of ALFs were classified as providing
minimal services.

The differences between high and low service ALFs were striking. High
service ALFs were more likely to be located on a multi-level campus and to have
a higher basic monthly rate structure, as shown in Exhibit
26.

The high service ALFs also had more overall nurse staffing compared to
the low service ALFs, including both RNs and LPNs. They were also less likely
to have most of their units as semi-private. More important, high service ALFs
were more willing than low service ALFs to admit and retain residents who could
be viewed as "heavier care," including residents with behavioral symptoms and
urinary incontinence, those who need help with locomotion and transfers, and
those who need nursing care. Further, high service ALFs were more willing to
retain residents with moderate to severe cognitive impairment and whose who
used wheelchairs. The effect of the services and the high service ALF admission
and retention policies can been seen in their resident characteristics. High
service ALFs were significantly more likely to have residents who received help
with three or more ADLs, according to administrator estimates.

The differences between high service ALFs and the low service ALFs that
were willing to provide or arrange nursing care were also examined, as shown in
Exhibit 27. This analysis was important since some
felt that the latter type of ALF, which typically arranged for nursing services
through a home health agency or similar provider, represented a desirable model
that could meet the scheduled and unscheduled needs of residents.

EXHIBIT 27. Comparison
Between High Service ALFs and Low Service ALFs Willing To Arrange Nursing
Services

As shown in Exhibit 27, there were significant
differences in nurse staffing between the two types of ALFs, with high service
ALFs having both more RN staffing and more staffing by LPNs. They were also
more likely to arrange or provide therapy services. What is interesting is that
these staffing differences were accompanied by differences in admission and
retention policies. Despite their stated willingness to arrange nursing
services, these low service ALFs were less willing than high service ALFs to
admit residents who:

Exhibited behavioral symptoms

Had urinary incontinence

Needed nursing care or monitoring (by RN or LPN)

Received assistance with locomotion; and

Received help with transferring

Similarly, the high service ALFs were more willing to retain residents
who:

Needed any nursing care or monitoring (by RN or LPN)

Needed nursing care for >14 days

Used a wheelchair

Received assistance with locomotion; and

Received help with transferring

These differences in admission and retention policies also played out in
resident case mix. The administrators in high service ALFs reported having a
resident population with a greater level of limitations in physical functioning
(i.e., more residents who received help with >3 ADLs) than that
reported for the low service ALFs that were willing to arrange nursing care.

In summary, the facilities classified as high service had more generous
admission criteria, more expansive retention criteria (allowing residents to
age in place longer), a higher resident case mix. They were also more willing
to arrange or provide extensive services (nursing care >14 days and
therapies).

7.3.3 Mix of Privacy and Services

While the effects of the single dimensions of services and privacy were
interesting, an ALF is, in operation, a mix of the two dimensions. Thus, the
analysis focused on describing the distribution of facilities across the cells
representing different mixes of services and privacy and on examining the
differences among the various types of ALFs. Exhibit
28 displays the distribution of assisted living facilities nationwide into
the dimensions of service and privacy. Combining the mix of services and
privacy revealed four basic types of ALFs.

The first type of ALF encompassed facilities in the "minimal" group of
ALFs (i.e., the 32% of ALFs that offered either minimal privacy or minimal
services) and facilities offering low privacy and low service (i.e., 27%
of the ALFs). The combined low/minimal privacy and services group was the most
common type of assisted living facility, comprising 59 percent of all the ALFs.

A second type of ALF offered a high degree of privacy in accommodations
but low services, a sort of "cruise ship" or hotel model of assisted living. An
estimated 18 percent of the ALFs fell into this category.

A third type of ALF offered high services but a relatively low level of
privacy. An estimated 12 percent of all ALFs fell into this category. As shown
in Exhibit 29, three-quarters of these ALFs (74%) were
facilities in which the majority of units were semi-private. One might think of
this model as having characteristics of the traditional nursing home
arrangement.

The fourth type of facility was in the "high privacy and high service"
category and comprised only 11 percent of all ALFs.

The effects of these different service and environmental models will be
examined in a subsequent set of reports that use more detailed facility, staff
and resident-level information. However, even the limited information
administrators were asked to provide during the telephone interviews revealed
interesting differences between the different types or models of ALFs, as shown
in Exhibit 29.

EXHIBIT 29. Differences in ALF
Characteristics Based on Combined Levels of Service and Privacy

Retention policies that were the same as
admission policies are not reported here.

The High Service/High Privacy (HS/HP) facilities were more likely
to be located on a multi-level campus and to have a higher proportion of
apartments. In addition, they were much more likely than average to have
all-private resident units (i.e., 75% of the HS/HP ALFs had no shared units).
Further, HS/HP ALFs that had several monthly rates, depending on the
accommodations or services provided to the resident, tended to have higher than
average monthly basic rates. By definition, they were more likely to have a
full-time RN on staff, but the difference in full-time RN staffing was striking
(e.g., 100% compared to an average of 13% among the low service facilities and
36% among the "minimal" ALFs). Similarly, they were more likely than any of the
low or minimal service facilities to have an LPN on staff as well (i.e., 76%
compared to <50%).

One interesting finding is that HS/HP ALFs did not have significantly
more expansive admission and retention policies or a more functionally impaired
resident case mix, relative to the overall mean rates. As noted earlier, there
were significant differences on admission and retention policies and resident
case mix between ALFs when they were categorized only on the basis of their
services. However, this trend toward more expansive admission and retention
policies was reversed for ALFs classified on the privacy dimension alone (i.e.,
high privacy facilities had no difference or had less expansive policies).
Thus, it appears in the case of ALFs that offered both high services and high
privacy the combination of services and privacy effectively cancelled out the
individual trends with respect to admission and retention policies.

The High Service/Low Privacy (HS/LP) ALFs were more likely to be
situated on a multi-level campus and more likely to have all types of nursing
staff. Unlike HS/HP ALFs, however, they had more expansive admission and
retention policies.

They were significantly more likely to admit and retain residents who
needed any nursing care and residents who needed help with transfers than other
facilities. Similarly, they were more likely to retain residents who needed
nursing care for more than 14 days. Finally, their admission and retention
policies showed in their resident case-mix, since HS/LP ALFs were significantly
more likely to have residents who received hands-on assistance with three or
more ADLs, particularly relative to both types of low service ALFs.

The Low Service/High Privacy (LS/HP) ALFs were more likely to be
self-described assisted living facilities. In addition, they appeared to be the
emerging model, with a length of time in business (an average of 10.8 years)
that was significantly lower than the other ALF types. Like the HS/HP ALFs,
they were more likely to have apartments than the average facility; however,
they were significantly less likely than the high service facilities to have
any RN on staff. LS/HP ALFs also had restrictive admission and retention
policies. They were less likely than the average ALF to admit or retain
residents with behavioral symptoms, those who needed nursing care, residents
with moderate to severe cognitive impairment, or those who needed help with
transfers. They were also less likely to retain residents with urinary
incontinence and residents who needed nursing home care for more than 14 days.
Finally, their admission and discharge criteria were reflected in their
resident casemix. According to the administrators, the LS/HP ALFs were
significantly less likely to have residents with moderate to severe cognitive
impairment and residents with functional limitations in three or more ADLs.

Compared to the other ALF types, the Low Service/Low Privacy
(LS/LP) ALFs had lower occupancy rates and were more likely to be
free-standing rather than located on a multi-level campus. They were also less
likely to have apartments than the average ALF. Further, they were
significantly less likely to offer 100 percent private accommodations to
residents. In 78% of the LS/LP ALFs, the majority of resident units were
semi-private. LS/LP ALFs were also significantly less likely to have any type
of nurse staffing and less likely to admit or retain residents who needed any
type of nursing care or monitoring. They were also significantly less likely to
have residents who received hands-on assistance with three or more ADLs.
Finally, the monthly price in LS/LP ALFs that had a "multi-rate" pricing
structure was significantly lower than average basic monthly rate in the other
types of ALFs.

The Minimal ALFs included all facilities that offered either
minimal privacy or minimal services. These ALFs, like the LS/LP facilities,
were less likely to be located on a multi-level campus and more likely to offer
rooms rather than apartments. They were also significantly less likely to have
all-private units. In fact, the majority of resident accommodations were
semi-private or ward-type rooms in more than two-thirds (70%) of the minimal
ALFs. In terms of admission and retention policies, they were more likely than
all but the HS/LP ALFs to admit residents with behavioral symptoms. However,
ALFs in this category were less likely than the average ALF to admit residents
who used a wheelchair and less likely to retain residents who used a wheelchair
or who needed any type of nursing care. Finally, their monthly basic rates were
lower than average.

In summary, it is clear from the information reported by ALF
administrators that there were significant differences among assisted living
facilities and that some distinct types emerged.

First, there were differences in accommodations not merely in terms
of privacy for residents in their units but also in the proportion of
apartments. The 59 percent of the ALFs categorized as low privacy/low service
or minimal privacy or service were much less likely to offer private units and
much less likely to offer apartment accommodations.

Second, there were significant differences in nurse staffing, not
merely for RNs but also for LPNs. Regardless of the type of environment they
offered, the high service ALFs were consistently more likely to have more
availability of some type of nurse staffing.

Third, both privacy and service dimensions capture important
features of ALFs; however, the interaction or mix of services and privacy
appears to modify the effect of a single dimension. For example:

The ALFs with the most expansive admission and retention
criteria were the category of homes known as high service/low privacy.

The ALFs offering high services/high privacy did not have more
expansive admission and retention criteria than the average ALF. Further, they
were the most restrictive in terms of admission or retention of residents with
behavioral symptoms and retention of residents with moderate to severe
cognitive impairment.

The ALFs offering high privacy and low services had the most
restrictive admission and retention criteria, particularly with respect to
residents who might need nursing care or monitoring or hands-on assistance with
transfers.

Fourth, the admission and retention criteria adopted by many ALFs
represent a potential limitation for many residents with Alzheimer's disease or
other dementias. For many such individuals, the ultimate trajectory of their
cognitive performance involves decline and for some includes the likelihood of
having behavioral symptoms at some time during the course of the disease.
However, fewer than half of the ALFs were willing to retain residents with
moderate to severe cognitive impairment. In only those ALFs classified as high
service/low privacy (50%) or minimal service or privacy (50%) did at least half
the administrators indicate a clear willingness to retain residents with
moderate to severe cognitive impairment. Moreover, with the exception of low
privacy/high service ALFs, fewer than one-quarter of the ALFs were
unequivocally willing to retain residents with behavioral symptoms. Thus, it
would appear that with respect to many ALFs, individuals with Alzheimer's
disease or other dementias may have fewer options in terms of privacy, high
services, and apartments, particularly if the resident's cognitive performance
declines as the resident ages in place.

Finally, the differences in basic monthly price were fairly
predictable. Low service/low privacy and minimal service or minimal privacy
ALFs tended to have the lowest monthly rates, on average, while the high
privacy/high service ALFs had the highest rates. The low privacy/high service
and high privacy/low service ALFs fell in between.

The different types or models of assisted living that emerged illustrate
the fallacy in assuming that "an assisted living facility is an assisted
living facility." Moreover, they highlight the challenges faced by
consumers who are attempting to determine whether "assisted living" can meet
their needs or to select a particular facility.

This section of the report presents information provided by the
administrators of a national probability sample of ALFs on the basic monthly
prices charged by ALFs. A forthcoming report will present additional data on
charges, based on more extensive interviews with the administrators, residents
and families.

As shown in Exhibit 30, the administrators
reported that the vast majority of facilities (82%) had more than one basic,
monthly rate. These ALFs had rates that varied depending on such factors as the
nature of the accommodations, the services provided to the resident, or
both.45

ALF administrators also reported considerable variation in basic rates.
For example, administrators reported rates that ranged from a low of $ 300 per
month to a high of $7,130 per month or from $3,600 per year to more than
$85,000 per year. However, these extremes are not representative of the usual
rates charged. For facilities with a multiple rate structure, the average
lowest basic rate was $1,338 per month or about $16,000 per year. The average
highest basic rate was $2,137 per month or almost $26,000 per year. The most
common basic monthly rate, however, was about $20,500 per year for ALFs with a
single rate structure and almost $19,000 per year for ALFs with multiple rates.

In considering these reported rates, it is important to note that the
facilities were extremely varied in the accommodations and services offered.
Further, as shown in the preceding section of this report, rates varied
tremendously according to the level of privacy and services offered by the
facility.

Exhibit 31 displays the distribution of the
monthly charges across major price categories and the price structure
encountered by residents. As shown, the most common monthly price range was
between $1000 and $1999 per month or $12,000 to $24,000 per year. Among ALFs
with single rate structures, 45 percent fell into this rate group. Among ALFs
with multiple rate structures, about half (52%) had basic monthly rates within
this group.

It is important to note that the average monthly price was skewed by the
presence of a very large number of ALFs (i.e., 59%) that offered minimal or low
privacy and services and had lower than average prices, as shown in
Exhibit 32. For example, the most common price for
"minimal" ALFs with multiple rates was $1,373 per month, while for low
service/low privacy ALFs, it was $1,458. The fact that these low privacy and
low service ALFs constituted more than half of the ALFs (59%) nationwide meant
that their significantly lower rates brought down the average basic monthly
price for all ALFs. The most common monthly price for high service/high privacy
ALFs was $1,940 per month or more than $23,000 per year. Similarly, the average
most common rates for high service/low privacy facilities and for low
service/high privacy facilities were $22,000 and just over $21,000 per year,
respectively. For the average highest monthly rate reported by administrators
for high service/low privacy facilities and low service/high privacy ALFs, the
annual rates were $29,000 and just over $26,600. Thus, residents who were
seeking either a high level of services or high privacy could expect to pay
considerably more than the industry average -- about 33 percent more than the
average basic rate for low service/low privacy facilities and about 40 percent
more than the average rate for "minimal" facilities.

It is also important to place the price charged for assisted living in
perspective, given the income of older persons. As shown in
Exhibit 33, the income of most persons aged 75 and
older in 1997 would have been insufficient to cover the basic monthly price for
the majority of assisted living facilities, according to data provided by the
U.S. Bureau of the Census in the Current Population Survey.46 As shown, more than 60 percent
of the ALFs had a basic monthly price of $15,000 per year or higher. However,
only about one-third (36%) of persons aged 75 or older had incomes this high.
Given the fact that the basic monthly price does not cover ancillary services
or such costs as clothing, insurance, medications, and so on, the actual annual
expenses of residents in ALFs was likely quite a bit higher than the basic
rate. Thus, even fewer of persons aged 75 or older would have been able to
afford residence in an ALF if they used only their income.

EXHIBIT 32. Differences in Average
ALF Prices--Based on Combined Levels of Service and Privacy

Finally, the reader is cautioned about making direct comparisons of
costs between the monthly basic rate for assisted living and that for nursing
homes. First, as noted earlier, the resident characteristics and care needs are
very different, with nursing homes, on average, having a much "heavier" case
mix. Second, nursing home per diems typically cover not only all personal care
and nursing care but also such other costs as medications, laundry,
incontinence supplies, and so on. With the exception of some personal
assistance, these are typically not covered in the monthly price set by ALFs.
Third, there are some indications that nursing homes reduce residents' use of
Medicare-covered health services, particularly hospital costs, while residents
in assisted living and residential care facilities may incur higher costs of
this type, although this is an issue under debate (Leon et al., 1999; Phillips
et al.,1998). Thus, more data are needed to address fully the cost of assisted
living.

As the preceding sections have shown, there is a large and growing
supply of places known as assisted living facilities that, as of the beginning
of 1998, were providing care to more than one-half million frail older persons.
Assisted living holds out the promise of dramatically affecting the provision
of long-term care. Its philosophy of emphasizing the dignity, autonomy, and
independence of older persons is one that should inform the entire long-term
care sector from home and community-based care to all forms of residential
long-term care, including nursing homes. Further, its philosophy of providing
services to meet the scheduled and unscheduled needs of older persons should
enable the frail elderly to age in place. One should be able to have
residential settings in which services change to meet the needs and preferences
of residents as opposed to the too-frequent situation of older persons being
shuffled from one setting to another in order to secure needed services as
their needs change over time. Finally, the philosophy of assisted living, if
implemented, should lead to residential environments that are much closer to
the preferences of older persons than those offered by the current supply of
traditional board and care facilities and nursing homes.

Given the vast promise of assisted living, the information garnered from
this first survey of a nationally representative sample of assisted living
facilities raised a number of issues and questions.

1. WHAT IS ASSISTED LIVING?

As noted earlier, attempts to understand assisted living and its role in
providing long-term care to the frail elderly have been hindered by the lack of
a common definition of "assisted living." One of the clear findings from this
study is that there was enormous variation among the places known as "assisted
living facilities." Assisted living is still a relatively new industry, and it
is one that has not developed in an orderly, planned manner. Both market forces
and public policy have contributed to a multiplicity of models and facility
types within the broad umbrella term of "assisted living." However, even within
the study's restrictive eligibility criteria, places known as ALFs differed
widely in ownership, auspice, size, and philosophy. Indeed, the responses by
administrators suggested several different models within the broad rubric of
"assisted living." Each model or type had different patterns with respect to
services, staffing, policies on admission and retention of residents,
accommodations, and price. Thus, based simply on a description of the
multiplicity of facility types, it is difficult to say what "assisted living"
is.

Typology and Distribution of ALFs by Levels of
Service and Privacy

Category

National Estimate

High Privacy
& High Service

11%

High Privacy
& Low Service

18%

Low Privacy
& High Service

12%

Low Privacy
& Low Service

27%

Minimal
Privacy or Minimal Service

32%

Another difficulty inherent is answering the question -- "what is
assisted living" -- derives from disagreement over which of the models
identified best captures the philosophy of assisted living. Some would argue
that the high service/high privacy model best exemplifies the philosophy of
assisted living since it captures both key environmental dimension (i.e.,
privacy) and offers residents the widest range of services, which should
facilitate aging in place another key component of the philosophy.
Unfortunately, the high privacy/high service ALFs did not appear to have
admission and retention policies consistent with aging in place, unless one has
a circumscribed definition. (This is discussed below.) Moreover, this type of
ALF constituted only 11 percent of the industry in 1998.

On the other hand, one might argue that assisted living explicitly
rejects a "medical model" of long-term care, including the requirement of RN
staffing. In this view, the high privacy/low services model could conceivably
be regarded as best capturing the chief philosophical tenets of assisted
living, particularly for those ALFs that were willing to arrange nursing and
therapy services as needed by residents. The difficulty is that such ALFs had
neither service patterns nor the admission and retention policies consonant
with meeting residents' scheduled and unscheduled needs or enabling them to age
in place. In essence, such facilities had higher than average costs and lower
than average resident case mix, which raises questions about whether this model
embodied the philosophy of assisted living.

Finally, many would argue that other models, such as the low privacy/low
service ALFs and the "minimal" ALFs, which constituted more than half the
supply of facilities, appeared to be much closer to the traditional domiciliary
care or board and care model of residential care, with few services and
considerably less privacy than seem inherent in the concept of assisted living.
However, there is disagreement among members of the industry that describe
themselves as assisted living facilities over whether such environmental and
service features are a necessary component of the ALF concept.

Given this variability among ALFs and the lack of agreement on an
operational definition of assisted living, the answer to the question --
"what is assisted living" -- appears to be that it is many different
things, at present. In effect, the term "assisted living" may be more useful to
providers as a marketing tool than it is to consumers or policy-makers as a
useful descriptor that would distinguish assisted living from other residential
long-term care settings. This represents a real challenge for older persons and
their families as they attempt to determine whether assisted living is a viable
alternative and to select an ALF that has the environment, services, staffing,
and policies that will meet their needs.

2. DOES THE ENVIRONMENT OF ASSISTED LIVING FACILITIES
MATCH THE PHILOSOPHY OF ASSISTED LIVING?

Based on the information provided by ALF administrators, the answer to
this question is clearly mixed. On the one hand, residents of assisted living
facilities had considerably more privacy than residents of most nursing homes
and the majority of board and care homes. On the other hand, there was
significant variability within the assisted living industry, and some
facilities provided environments that did not appear consistent with the
environmental aspects of the assisted living philosophy. Further, the answer is
preliminary, since other key features of the environment and resident
satisfaction with them will be examined in a subsequent report.

In many respects, the supply of facilities did match key elements of the
philosophy of assisted living. First, ALF accommodations, overall, met
residents' preferences for privacy. Most (73%) resident units were private, and
most residents (62%) also had a private full bathroom, while another six
percent had at least a private half-bath. Second, the environments offered some
important choices to consumers. Most assisted living facilities, for example,
offered consumers some choice in terms of privacy. Only 27% of the facilities
had all private units. Thus, in the vast majority of ALFs, consumers had some
opportunity to share a room or apartment, if they so desired. Further,
consumers had choices among ALFs based on whether they offered apartments or
rooms. Forty-three percent of the resident units were apartments.

At the same time, a large number of ALFs had environmental features that
were arguably inconsistent with the philosophical tenets of assisted living. As
noted, 28 percent of the ALFs had one or more rooms that housed three or more
unrelated persons a model considered incompatible with the concept of "assisted
living." Further, in more than one-quarter (26%) of the ALFs nationwide, only
semi-private units were available. In addition, in slightly more than half the
ALFs (52%) nationwide, fewer than half the resident units were private. These
are settings that would appear incompatible with the general thrust of the
assisted living philosophy, although as noted above, some would disagree.

There is less agreement about whether apartments are an essential part
of the assisted living model of care. To some, the availability of apartments
and the autonomy that entails for consumers is a hallmark of assisted living.
Certainly, that was the model that started in the United States in Oregon.
However, it was not the dominant model in the industry. Sixty-eight percent of
the ALFs offered only rooms (not apartments) as accommodations, and rooms were
the dominant unit type (i.e., an estimated 57% of all resident units). Further,
only six percent of the ALFs offered consumers a choice by having a mix of
rooms and apartments.

In summary, the majority of residents' accommodations met the key
criteria of privacy, embodying, in part at least, a key element of the assisted
living environmental philosophy. Similarly, many facilities offered a range of
choices to consumers. At the same time, there was considerable variation in the
industry both in terms of privacy and in the provision of apartments. This was
particularly true at the "low-end" of the price market, which was dominated by
the low and minimal privacy ALFs. This raises the possibility that low and
moderate income older persons will have access to board and care-type
facilities, while only well-to-do elderly will have access to the types of
environmental models that seem to embody key elements of the assisted living
philosophy.

3. DO ASSISTED LIVING FACILITY SERVICES MATCH THE
PHILOSOPHY OF ASSISTED LIVING?

The philosophy of assisted living addresses a variety of issues related
to services, including, for example, how services are provided (i.e., so as to
maintain the resident's dignity and independence) and how service arrangements
are negotiated between the consumer and provider. Thus, the philosophy of
assisted living encompasses key concepts of consumer choice and autonomy in
relation to services. In addition, the assisted living concept speaks to the
provision of services to meet the scheduled and unscheduled needs of residents
and of the desirability of helping residents age in place by altering services
as residents' needs and preferences change.

The data from this set of interviews with administrators was quite
limited with respect to answering this question about services, but they did
provide some initial results about this important issue.

Nearly all the ALF administrators reported that they provided or
arranged basic hospitality, supervision, and personal assistance services.
These would be sufficient to meet residents' basic needs for help with
instrumental activities of daily living (IADLs), such as housekeeping, meal
preparation, medications, and at least basic assistance with early-loss ADLs,
such as bathing and dressing. In addition, the vast majority (80%) of ALFs
indicated they would provide or arrange some nursing care and, if needed,
therapies (74%).

At the same time, the amount or extent of nursing care that would be
made available was limited. First, just over one in five ALFs (21%) would not
arrange or provide any nursing care or monitoring. Second, only about half
(55%) the ALFs reported having an RN on staff full- or part-time, and only 40
percent had a full-time RN. This limited the ability of those ALFs with little
or no RN services to assess residents' health care needs, including unmet care
needs, medication reactions or interactions, and access to preventive health
care services and limit their ability to develop care plans that would maximize
residents' functional well-being. Although a social model of care can exist in
a facility that has an RN on staff, residents' ability to remain physically
independent and socially active may be enhanced by systematic assessment and
monitoring by a nurse.

The implication of this is that for some residents, even a short-term
illness could not be handled in the ALF in which they lived. In fact, in focus
group interviews, many assisted living residents reported dissatisfaction with
the fact that even an episode of a temporary illness such as influenza would
result in a transfer to a hospital or nursing home (Hawes and Greene, 1998).

Thus, the ability of assisted living facilities to meet unscheduled
health-related needs is probably still an open question in part because of
facility policy and in part because of potential constraints imposed by state
licensure regulations and nurse practice acts.47

4. DO ASSISTED LIVING FACILITIES ALLOW OLDER PERSONS TO
AGE IN-PLACE?

It probably begs the question to say that the answer to this question
depends on how you define "aging in place." However, the operational definition
of aging in place one adopts determines whether ALFs are regarded as promoting
aging in place or as incompatible with the concept.

Aging in place could be conceived of as spanning only a limited segment
of a potential change in a resident's health and physical and cognitive
functioning. For example, many facilities were willing to accommodate a
consumer whose needs changed from requiring relatively little help (e.g., meal
preparation, housekeeping) to the stage at which the resident required help
with bathing, dressing, and managing medications or used a wheelchair to get
around. If this were the operational definition of aging in place, then the
admission and retention policies of assisted living facilities suggested that
they were willing to allow residents to age in place.

On the other hand, aging in place could be conceived of as a more
expansive concept. It could mean that the average consumer could select an
assisted living facility and reasonably expect to live there to the end of his
or her life, regardless of changes in health or physical and cognitive
functioning. If this were one's definition of aging in place, then the answer
about whether ALFs allow aging in place would more often be a "no." The
majority of ALFs reported they would not retain residents who needed help with
transfers (54%) or who needed nursing care (68%). In fact, the vast majority
(72%) would not retain a resident who needed nursing care for more than 14
days. More troubling, given demographic and morbidity trends, most facilities
(55%) reported they were unwilling to retain residents with moderate to severe
cognitive impairment, and only 28% would retain residents with behavioral
symptoms. Further, three-quarters of the facilities (72%) reported that during
the preceding six months, they had discharged one or more residents because
they needed nursing care. Thus, whether because of facility policy or state
regulations, most ALFs would not allow residents to age in place across the
full spectrum of potential changes in need. At the same time, some ALFs,
particularly the high service/low privacy ones, reported willingness to allow
substantial physical and cognitive status limitations among residents but still
retain the resident and provide or arrange the needed services.

Do ALFs Serve as a Viable Alternative to Nursing Homes? Because
of the limitations ALFs placed on their resident mix, as evidenced by their
admission and retention policies, the answer to this would have to be "no" for
the majority of facilities. Further evidence supporting this position comes
from an examination of the administrators' reports about resident
characteristics. According to estimates by the administrators, only about
one-quarter of ALF residents (24%) received help with three or more ADLs, while
more than four in five (83%) of nursing home residents had such functional
limitations. Similarly, only about one-third of ALF residents were estimated to
have moderate to severe cognitive impairment, whereas more than two-thirds of
nursing home residents were cognitively impaired. Thus, there may have been
some overlap of residents at the "higher acuity" or "heavier care" end of
assisted living and the "lower acuity" end of nursing homes. However, for the
majority of homes and residents, the two types of facilities had somewhat
distinct positions and functions in terms of the staffing and services they
provided and the consumers they served.

It is important to note that a variety of forces militate against
assisted living facilities serving as an alternative to nursing homes. These
include preferences of many ALF residents to live in settings and with other
residents who do not look "too much like a nursing home;" the concerns of state
regulators; the interest and political power of the nursing home lobby; and the
conception ALF owners and administrators have of their "niche."

5. IS ASSISTED LIVING AVAILABLE TO LOW OR MODERATE
INCOME OLDER PERSONS?

Assisted living was largely unaffordable for moderate and low-income
older people. Forty percent of all people aged 75 and older had incomes below
$10,000 per year in 1997. Nearly two-thirds had incomes below $15,000 (U.S.
Bureau of the Census, 1998). Thus, two out of three older persons could not
afford even the most common basic monthly price of assisted living (i.e.,
almost $19,000 a year in multi-rate facilities). Indeed, they could not afford
the most common monthly rate in even the low privacy/low service or minimal
facilities (i.e., average annual basic prices of about $17,500 and $16,500,
respectively).

Within this generalization, there were some exceptions. Some facilities,
for example, reported charging less than $1,000 per month or $12,000 per year.
However, these facilities were more likely to offer few services and little
privacy. In other words, low income elders would have mainly had the option of
an ALF that was most like traditional "board and care." While there were a few
exceptions to this general rule, they were mainly small-scale, experimental
programs or were situated in the few states, like Oregon, that had included
payments for assisted living in their Medicaid budgets (i.e., for the personal
care services not the room and board costs) and had set acceptable payment
rates. Waiver programs that funded assisted living, while growing, did not
serve large numbers of elderly (Mollica, 1998). And in any event, they were
restricted to persons who met state Medicaid eligibility criteria. The vast
numbers of near-poor and moderate-income elderly could neither afford most
assisted living facilities nor qualify for public payments.

There are two other ways persons with low or moderate incomes could pay
for assisted living. First, they could spend-down any assets they might have,
using the additional funds to supplement their income and pay for the ALF.
Second, they could receive assistance in paying for assisted living from a
relative. Unfortunately, this survey did not address these possibilities. A
subsequent report, however, will provide information on the income of a
national probability sample of residents and will help determine the extent to
which low and moderate income individuals reside in ALFs and the type of ALFs
in which they reside.

Dunah, R., Harrington, C., & Bednew, B. (1993). Variations and
trends in licensed nursing home capacity in the states, 1978-1992. San
Francisco: Institute on Health and Aging, University of California.

General Accounting Office, U.S. Congress (1997). Consumer
protection and quality of care issues in assisted living. Washington,
DC: U.S. Government Printing Office.

Gulyas, R. (1997). The not-for-profit assisted living industry:
1997 profile. Washington, DC: American Association of Homes and
Services for the Aging.

Harrington, C., DuNah, R., Bedney, B., & Carillo, H. (1994).
Variations and trends in licensed nursing home capacity in the states,
1978-1993. San Francisco: Institute for Health and Aging, University of
California at San Francisco.

Mullen, A. (1997). The assisted living industry: A critical
assessment from 1997 forward. Presentation at the Assisted Living
Market Research and Feasibility Summit sponsored by the National Investment
Conference.

National Investment Conference (1998). National survey of assisted
living residents: Who is the customer. Annapolis, MD: M. Wylde.

Newcomer, R. (1999). Personal communication about study of assisted
living in California.

Newcomer, R.J., Lee, P., & Wilson, K.B. (1997). Residential care for
the frail elderly: State innovations in placement, financing, and governance.
San Francisco: Institute for Health and Aging, University of California at San
Francisco.

U.S. Bureau of the Census (1997). Published data from the 1998 Current
Population Survey, "Money Income in the United States, 1997" (Series P60-200),
Table 8, Income Distribution of Older Persons, 1997.

U.S. House of Representatives, Select Committee on Aging (1989).
Board and care homes in America: A national tragedy. Report by
the Chairman of the Subcommittee on Health and Long-Term Care, House of
Representatives, Comm.Pub.No. 101-711.

Sloane, P. & S.I. Zimmerman, personal communication. (1999). Drs.
Sloane and Zimmerman and their colleagues are conducting a longitudinal study
of residents in ALFs, nursing homes and traditional board and care homes in
four states in a study funded by NIA and AHCPR.

FACILITY SCREENING QUESTIONNAIRE

**NOTE** The letter "B" brackets [B] in many of the variable names is a
token that represents one of 7 possible letters that could be found in this
position. The letters represent the section of the facility being asked about,
and follows the lettering system defined in Question 1 (e.g., B=Assisted
Living, C=Congregate Care, etc.) Not all letters in the list are represented
since some units were ineligible for continued questions.

SNGMULTA

1.

Is this a facility that provides multiple levels of care, such as
nursing home, assisted living, residential care, or independent living at the
same
location? 1 YES
(GO TO
MULTI1@01) 2 NO

2.

Which of the following types or levels of care does your facility
offer?

YES=1 NO=2 YES/NO

MULTI101

a)

licensed nursing home

MULTI102

b)

assisted living

MULTI103

c)

congregate apartments/congregate care

MULTI104

d)

independent living/independent apartments

MULTI105

e)

board and care/personal care/residential care

MULTI106

f)

continuing care retirement community or life care community

MULTI107

g)

designated Alzheimer's Special Care Unit in a residential care or
assisted living section of the facility

MULTI108

h)

designated Alzheimer's Special Care Unit in a licensed nursing
home

MULTI109

i)

rehabilitation hospital/subacute care unit

MULTI110

j)

hospital

MULTI111

k)

Other (SPECIFY)

FOR EACH OF THE ABOVE TYPES
OF CARE THE FACILITY SAYS THEY OFFER (THAT WE ARE INTERESTED IN) WE WILL ASK
THE FOLLOWING:

MULTI2[B]A

3.

How do you refer to this assisted living section? (Or
congregate care, or independent living)

Q1U[B]A

1.

Excluding any nursing home beds, do you have 11 or more beds in
(the) NAME OF TYPE OF CARE SPECIFIED ABOVE
(section)? 1 YES
2 NO (SKIP to
end of interview)

Q3U[B]A

3.

Excluding any nursing home residents, are at least half of the
residents 65 years of age or older?Excluding any nursing home beds, do you have
11 or more beds in (the) NAME OF TYPE OF CARE SPECIFIED ABOVE
(section)? 1 YES
2 NO (SKIP To
END OF INTERVIEW)

Q4U[B]A

4.

Do you refer to (the) (SECTION NAME FILL) (section) as an assisted
living facility or do you advertise that you provide assisted living services
in that section? This includes such things as having the phrase assisted living
in the name of the facility or in any advertisements about what the
(section/facility) provides.Excluding any nursing home beds, do you have 11 or
more beds in (the) NAME OF TYPE OF CARE SPECIFIED ABOVE
(section)? 1 YES
2 NO

I am now going to ask about specific services the (SECTION NAME FILL)
(section) may offer. Please tell me whether you regularly provide or
arrange for their provision with an outside agency. By "arranging," we mean
that you have a formal contract with the agency or that the facility takes
responsibility for helping the resident arrange to receive the service. That
would include identifying resident needs, contacting an agency or provider, and
monitoring the performance of the service. "Regularly" means not on an ad hoc
or for only one special resident.

5a.

Do you regularly provide or
arrange..

[Yes=1 No=2]

IF THE RESPONDENT SAYS "YES" FOR A
SERVICE, ASK:

5b.

Do you provide this service with staff who work
for the facility or do you arrange the service with an outside
agency?

Services

YES(1)/NO(2)

PROVIDE(1)/ARRANGE(2)/BOTH(3)

a.

housekeeping

Q5AU[B]H

Q5AU[B]H2

b.

at least two meals per day

Q5AU[B]OM

Q5AU[B]OM2

c.

three meals a day

Q5AU[B]EM

Q5AU[B]EM2

d.

24-hour direct care staff who can respond to resident's needs for
assistance or monitoring

Q5AU[B]DC

Q5AU[B]DC2

e.

medication reminders to residents

Q5AU[B]MR

Q5AU[B]MR2

f.

central storage or assitance with self-administration of
medications

Q5BU[B]ST

Q5BU[B]ST2

g.

assistance with bathing

Q5BU[B]BT

Q5BU[B]BT2

h.

assistance with dressing

Q5BU[B]DR

Q5BU[B]DR2

i.

any care or monitoring by a licensed nurse (i.e., an RN or
LPN/LVN)

Q5BU[B]MN

Q5BU[B]MN2

j.

any therapy services (e.g., speech, physical, occupational
therapy)

Q5BU[B]TH

Q5BU[B]TH2

6.

How long has (the) (FACILITY NAME FILL) (section) been
in operation?IF LESS THAN 1 YEAR, CODE 00 FOR YEARS AND INDICATE NUMBER OF
MONTHS. IF RANGE GIVEN, ACCEPT THE LOWEST ESTIMATE.

Q6U[B]YRS _____YEARS

Q6U[B]MNTS _____MONTHS

IF IN BUSINESS FOR LESS THAN 3 MONTHS, STOP AND GO
TO "GOODBYE"

DECIU[B]

6a.

Can you answer some more detailed questions about
services and accommodations in (the) (SECTION NAME FILL) (section) or should I
contact someone
else? 1 I can
answer 2 Contact
someone else

INTRODUCTORY STATEMENT TO BE READ BEFORE Q9. FOR ONLY THOSE WHO ANSWER
Q.7B.

In your response to the next questions, consider only those beds or
units identified as part of (SECTION NAME FILL).

Q9U[B]A

9a.

How many beds are currently in operation or available for residents
in the (SECTION NAME FILL) (section)? NOTE: SHOULD BE AT LEAST
11.__________

Q9U[B]B

9b.

How many residents are currently living in (the) (SECTION NAME
FILL) section?__________

Q11U[B]A

11.

Do any of the resident bedrooms (including those in apartments)
house more than 2 unrelated
people? 1 YES
2 NO

Q12AU[B]A

12a.

Now, I'd like to ask you about the type of accommodations you
provide in (the) (SECTION NAME FILL) (section). By "apartment," we mean a
bathroom, bedroom, living room, and kitchen or kitchen area. A studio apartment
is also included. Are any apartments in (the) (SECTION NAME FILL)
(section)? 1 YES
2 NO (SKIP to
Q.13a)

Q12BU[B]A

12b.

What is the total number of apartments in your
facility?__________

12c.

Please tell me the number of your accommodations that are described
by the following:

Semi-private bedroom and communal bathroom (shared by more
than 2 rooms)

Q13BU[B]10

Bedroom shared by three or more related people

Q13BU[B]11

Other bedroom type (DESCRIBE)Q13CSU[B]A __________

Q14U[B]A

14.

We are also interested in learning if you have any "heavy care"
residents, that is those who require significant help with certain activities
of daily living or ADLs. This week, approximately what percentage of your
residents receive hands-on help from staff with ANY of the following ADLs"

getting around inside the facility (either walking or using a
wheelchair with assistance);

using the toilet;

transferring, that is moving from a bed to a chair or to
standing; or

eating

Percentage of residents: __________

Q15U[B]A

15.

We would also like to know if you are serving persons with moderate
to severe cognitive impairment. This means that residents have short-term
memory problems or poor ability to make decisions about their daily
lives.This week, approximately what percentage of your residents are
cognitively impaired?Percentage of residents: __________

Q16AU[B]A

16a.

Do you have a Registered Nurse (RN) on staff who works at least 40
hours per week? This includes contract
staff. 1 YES
(SKIP to
Q.17) 2 NO

Q16BU[B]A

16.b

Do you have an RN on staff who works less than 40 hours per
week? 1 YES
2 NO

Q17U[B]A

17.

Do you have a Licensed Practical or Vocational Nurse on staff who
works 40 or fewer hours per week? This includes contract
staff. 1 YES
2 NO

Some facilities have policies about the level of disability they can
serve. The next questions are about whether you would admit residents with
certain problems and whether you would retain residents who develop these
conditions.

Weighted data yielding national estimates. It
is important to remember that our population includes only those places that
(1) serve mainly older persons; (2) have 11 or more beds; (3) were in operation
as of late 1996 to early 1997 (and thus were on the sampling frame); & (4)
are either a self-described assisted living facility or a facility that offers
at least two meals a day, housekeeping, 24-hour staff, and assistance with
>1 ADL and medications or help with >2
ADLS.

We use the term "facility" to refer to
single-level or free-standing facilities and facilities that are part of
multi-level campuses, as well as "assisted living" units that may be a section
of another facility, such as a nursing home.

Rounding errors account for differences in some
estimates; also, different numbers of respondents to some items (e.g., number
of beds and number of residents) may lead to slight differences in weighted
estimates.

* Significant at P<.01** Significant at
P<.001

TABLE B10. Comparison Between
Single-Level and Multi-Level Facilities--Privacy and Services

Facility Characteristic

All Facilities

Free- Standing

Multi- Level

LEVEL OF PRIVACY

% of
facilities that are high privacy (>80% of
accommodations are private)5

31.3%

22.8%

41.5%**

% of
facilities that are low privacy (>21% of accommodations
are semi-private)

40.3%

41.4%

39.1%

% of
facilities with minimal privacy (>1 bedroom shared by 3
persons)

28.4%

35.8%

19.5%**

Percent of
facilities with 100% private accommodations

26.7%

19.8%

35.0%**

Percent of
facilities with <50% private accommodations

51.8%

63.2%

38.2%**

LEVEL OF SERVICES

% of
facilities that provide high services (RN on staff at least 40
hours per week and provides nursing care with own
staff)

30.6%

19.9%

43.5%**

% of
facilities with low services

65.0%

76.4%

51.4%**

% of
facilities with minimal services (does not offer assistance with >2
ADLs or >1 ADL and medications)

*
Significant at P<.01** Significant at P<.001*** "Other"
facilities, that is those that did not self-identify as ALFs, were required to
provide these services to be eligible for the survey; thus, the statistically
significant differences are a product of different eligibility
rules.

TABLE B15. Comparison Between
Self-Described ALFs and Other Eligible Facilities--Retention and Admission
Policies

*
Significant at P<.01** Significant at P<.001*** "Other"
facilities, that is those that did not self-identify as ALFs, were required to
provide these services to be eligible for the survey; thus, the statistically
significant differences are a product of different eligibility.

TABLE B17. Comparison Between High
and Low Service Facilities--General Characteristics

Facility Characteristic

All

Low Service

High Service

GENERAL CHARACTERISTICS:

Total
estimated number of eligible facilities

11,4591,2

7,450(65.0%)2

3,511(30.6%)2**

Total
estimated number of beds

611,300

344,3002

226,002

Total
estimated number of residents

521,500

288,1002

197,5002

Total
estimated occupancy rate nationwide

84.3%

83.2%

86.2%

% that are
self-described ALFs

71.5%

69.7%

71.6%

% that are
part of multi-level campus

45.5%

36.0%

64.6%**

Average
length of time in business

15.0 yrs.

14.1 yrs.

17.4 yrs.

Average bed
size

53.3 beds

46.2 beds

64.4 beds**

Average
number of residents

45.5 res.

38.7 res.

56.2 res.**

RATES

For
facilities with single rate, average monthly rate:

$1710

$1596

$2033*

For facilities with multiple rates:

Average
lowest monthly rate

$1338

$1268

$1524**

Average
highest monthly rate

$2137

$1989

$2489**

Average most
common monthly rate

$1582

$1481

$1838**

Rounding errors account for differences in some
estimates; Also, different numbers of respondents to some items (e.g., number
of beds and number of residents) may lead to slight differences in weighted
estimates.

There are an additional estimated 498
facilities (4.3% of the facilities) that have minimal services and are excluded
from this analysis.

* Significant at P<.01** Significant at
P<.001

TABLE B18. Comparison Between High
and Low Service Facilities--Privacy and Services

Facility Characteristic

All Facilities

Low Service

High Service

LEVEL OF PRIVACY

% of
facilities that are high privacy (>80% of accommodations are
private)5

31.3%

28.3%

35.7%

% of
facilities that are low privacy>21% of accommodations are
semi-private)

40.3%

41.4%

37.9%

% of
facilities with minimal privacy (>1 bedroom shared by 3
persons)

28.4%

30.3%

26.5%

Percent of
facilities with 100% private accommodations

26.7%

24.8%

30.7%

Percent of
facilities with <50% private accommodations

51.8%

55.9%

44.2%**

*
Significant at P<.01** Significant at P<.001

TABLE B19. Comparison Between High
and Low Service Facilities--Retention and Admission Policies

Average percent of residents with moderate to severe cognitive
impairment

34.1%

33.3%

37.7%

*
Significant at P<.01** Significant at P<.001

TABLE B21. Comparison Between High
and Low Privacy Facilities--General Characteristics

Facility Characteristic

All

Low Privacy

High Privacy

GENERAL CHARACTERISTICS:

Total
estimated number of eligible facilities

11,4591,2

4622(40.3%)2

3585 (31.3%)2**

Total
estimated number of beds

611,300

241,200

201,600

Total
estimated number of residents

521,500

202,700

173,900

Total
estimated occupancy rate nationwide

84.3%

82.4%

85.6%*

% that are
self-described ALFs

71.5%

70.2%

78.7%*

% that are
part of multi-level campus

45.5%

44.1%

60.3%**

Average
length of time in business

15.0 yrs.

14.7 yrs.

13.0 yrs.

Average bed
size

53.3 beds

52.2
beds

56.2 beds

Average
number of residents

45.5 res.

43.9 res.

48.5 res.

RATES

For
facilities with single rate, average monthly rate:

$1710

$1762

$1872

For facilities with multiple rates:

Average
lowest monthly rate

$1338

$1332

$1512**

Average
highest monthly rate

$2137

$2115

$2317**

Average most
common monthly rate

$1582

$1561

$1791**

Rounding errors account for differences in some
estimates; Also, different numbers of respondents to some items (e.g., number
of beds and number of residents) may lead to slight differences in weighted
estimates.

There are an additional estimated 3252
facilities (28.3% of the facilities) that have minimal privacy and are excluded
from this analysis.

* Significant at P<.01** Significant at
P<.001

TABLE B22. Comparison Between High
and Low Privacy Facilities--Privacy and Services

Facility Characteristic

All Units

Low Privacy

High Privacy

LEVEL OF PRIVACY

Percent of
facilities with 100% private accommodations

26.7%

0%

74.6%**

Percent of
facilities with <50% private accommodations

51.8%

77.3%

0%**

LEVEL OF SERVICES

Percent of
facilities that provide high services (RN on staff at least 40 hours per
week and provides nursing care with own staff)

A previous study funded by DHHS/DALTCP focused
on licensed and unlicensed board and care homes. Two-thirds of those facilities
had 10 or fewer beds, and the study found that none of the small homes called
themselves assisted living. Few provided assistance with more than two
activities of daily living (ADLs). As a result, we concluded that the vast
majority of these small facilities would not provide the services generally
considered a fundamental part of assisted living. Further, the small homes
tended to serve a younger population of residents and a population that was
more likely to have mental retardation, developmental disabilities, or
persistent and serious mental illness. In addition, no states that licensed a
specific category known as "assisted living" reported any facilities with fewer
than 11 beds. For all of these reasons, ASPE and the project staff decided to
exclude small homes from this study of assisted living for the frail
elderly.

These results are based on the most detailed
information administrators provided about the accommodations (i.e., when they
provided an exact count of the number of apartments and rooms). In another item
on the survey, they were asked to estimate the distribution between rooms and
apartments. The responses to this other item indicated that administrators
estimated that 48% of the units were apartments and 52% were rooms.

Many facilities had idiosyncratic policies about
admission and retention. That is, the administrators responded "it depends"
when asked about whether the facility would admit or retain residents with a
specified condition. For example, one-quarter (26%) of the administrators
responded "it depends" when asked whether they would admit a resident with
moderate to severe cognitive impairment. One-third (33%) reported that "it
depends" when asked whether they would retain a resident with moderate to
severe cognitive impairment. When the "it depends" response was given,
it was counted as a "no" since residents and families could not rely on either
admission or retention in such instances.

The differences between facilities that had a
full-time RN and provided nursing care with their own staff and those that did
not have a full-time RN on staff but were willing to provide or arrange nursing
care are discussed at greater length in Section 7 of
this report.

U.S. Bureau of the Census, published data from
the 1998 Current Population Survey, "Money Income in the United States, 1997"
(series P60-200), Table 8, Income Distribution of Older Persons, 1997.

This is based on estimates of annual income.
More people could afford assisted living for some period of time by
selling their assets, such as a family home, and using those funds to pay the
monthly charges for assisted living.

In some states, there are multiple names and
multiple licensing agencies for different types of board and care
homes.

Some analysts and lenders became less
enthusiastic in the later part of the 1990s, noting oversaturation of some
markets, both in some geographic areas and, more particularly, at the "high
price" end of the market. In addition, some observers began to note that
facilities might have difficulty meeting the needs of a resident population
with significant health care needs and still maintaining the high profitability
level Wall Street had come to expect. The result more recently has been a
significant decline in lender and some investor ardor for assisted
living.

These include studies conducted by the U.S.
General Accounting Office and studies funded through grants and contracts from
the National Institute on Aging, the Agency for Health Care Policy and
Research, the Alzheimer's Association, the Robert Wood Johnson Foundation, and
the Hartford Foundation.

Subcontractors include Lewin, Inc. (Barbara
Manard), the University of Minnesota Long-Term Care Resource Center (Rosalie
Kane), and the National Academy for State Health Policy (Robert
Mollica).

Summaries of prior reports can be found on the
Homepage for the U.S. Department of Health and Human Services in the section
for ASPE's Office of Disability, Aging and Long-Term Care Policy. Full copies
of the reports can also be order at this site. The Internet address and mail
addresses for viewing or ordering these reports are shown on the inside of the
front cover of this report.

At the end of the project, a sample design
report will be submitted that covers all aspects of the study, including the
telephone survey and additional data collection and analysis.

The third stage involved selection of the
resident and staff samples for in-person interviews.

Nearly half the states lacked a licensure
category known as "assisted living" or classified such facilities together with
traditional "board and care" homes during the period in which we attempted to
enumerate a list of assisted living facilities (Mollica and Snow,
1996).

The second reason for first selecting a limited
number of geographic areas as FSUs was that it facilitated cost-effective data
collection on site in sample facilities, a subsequent data collection
task.

For example, the California Association of
Homes and Services for the Aging posted a state-wide list of places offering
housing with supportive services.

Some sources, such as most state licensure
lists, identified the county, while other lists (e.g., telephone book yellow
pages) did not.

For example, Menorah Park Center for Senior
Living had two different residential settings (i.e., Stone Gardens Assisted
Living and The R.H. Myers Congregate Apartments) that met study eligibility
criteria, although only one self-identified as an assisted living facility.
Both were on the same campus.

Facility candidates with unknown size were
undersampled to improve the cost effectiveness of the telephone screening. The
fact that they appeared, for the most part, on only one list, suggested that
they were small and less likely to meet study eligibility criteria. And indeed,
only 8 percent of the places with unknown size were found to be eligible during
the telephone screening and survey. Again, weighting the final sample adjusted
for this undersampling and generated valid estimates about the universe of
assisted living facilities.

A total of 48% of the listings were ineligible.
This includes the ineligible facilities that project staff were able to contact
(41.3%) and interview as well as listings (6.2%) that they were unable to
contact (i.e., with no obtainable telephone number or no response to
>10 telephone calls). We assumed that an eligible ALF would have a
listed telephone number and have someone on duty 24 hours per day who would
thus answer one of more than ten telephone calls. Therefore, we assumed that
places that could not be contacted were either out of business or not an
otherwise eligible facility.

It should be noted that five percent of the
places that identified themselves as an "assisted living facility" did not meet
the service eligibility criteria that were imposed on other facilities on the
list. However, because the project sought to describe the facilities that
represent themselves as part of the assisted living industry, they were
included in the descriptive segment of the study and in this report. These
facilities are discussed at greater length in Section
7.

Response rates for national surveys ranged from
six to 33 percent (Hodlewsky, 1998; Gulyas, 1997; ALFA, 1998). Higher rates
(i.e., 54%) were based on a replacement strategy for facilities that refused
(NIC, 1998). These generally low response rates for these other studies,
combined with issues related to their sampling strategies, make if difficult to
rely on them for generalizable data on the assisted living industry.

More detailed Tables, showing confidence
intervals or statistical significance for all estimates, appear in
Appendix B.

Most other studies did not restrict their
estimates to only those facilities that met a commonly accepted definition of
assisted living. Thus, they may base their estimates on membership figures or
listings in large retirement directories that include very small facilities and
facilities that provide few services. Similarly, licensure lists often include
facilities that do not meet the commonly accepted concept of assisted living.
For example, some states adopted rules that simply reclassified all board and
care homes as "assisted living" in their state licensure regulations (Mollica,
1998). As a result, such sources may include large numbers of facilities that
do not meet the ASPE study definition of assisted living.

That is, they provide, at a minimum, 24-hour
staff oversight, housekeeping, at least two meals a day, and help with at least
two of the following: medications, bathing, dressing.

Unfortunately we could not determine the actual
prevalence of SCUs from these items. Thus, describing the prevalence and
characteristics of ALFs offering specialized care for persons with dementia
will be done in a subsequent report, based on more detailed interviews with
administrators.

Privacy was defined as a bedroom (in a room or
apartment unit) that is not shared with an unrelated individual. Thus, a
"private" unit may house, for example, a married couple. Semi-private meant
that the bedroom was shared by no more than two unrelated individuals.

The next report from ASPE will present the
results of site visits to some 300 ALFs nationwide, including interviews with
administrators, staff, and residents, as well as a structured observation of
the facility by trained research staff.

The question was about whether the ALF bedroom,
whether in a room or an apartment, was private or shared. Thus, a "quad"
apartment in which residents had private bedrooms but shared a living room and
kitchen would be counted here as a "private" accommodation.

The study findings estimated somewhat greater
rates of shared rooms than other studies have reported. For example, a 1997
survey of the assisted living industry conducted for ALFA found that 86.1% of
the units in responding facilities were private, 13.2% were semi-private and
less than one percent (0.7%) of the units had three or more residents (ALFA,
1998). However, the findings from these other studies are limited by not being
drawn from a nationally representative sample of ALFs and by low response
rates.

A studio apartment is defined as an apartment,
while privacy was defined as occupancy by one individual, unless the occupants
were related by blood or marriage. In practice, state policy allowed a few
units to be shared, if the resident chose that option.

Administrators were asked to provide detailed
information on the exact nature of the accommodations they offered, including
the number of units in single rooms and the number in apartments (which
included studio apartments). Then, within each of those categories, they were
asked for the number of different types of units and bathrooms, as well as
whether the units were private or shared. These detailed reports are the basis
for the estimated distribution of units between rooms and apartments.

The question about apartments and privacy was
asked in terms of whether the bedroom portion of the apartment was shared or
private, since some facilities offer arrangements similar to "quads" in
dormitories with private bedrooms and shared living rooms. Greater detail on
the exact nature of residents' accommodations will be provided in a subsequent
report based on in-person interviews with administrators, staff and residents
in a sample of facilities.

We excluded the 5% of the apartments that were
classified in the "other apartment type" category from all the privacy
calculations.

In general, respondents were asked to answer
"yes" or "no" to the question of whether they would admit or retain a resident
with a given condition. In Exhibit 21 and in the data
reported here, only the unequivocal "yes" responses were counted as indicating
a policy to admit or retain a resident with the specified need or condition.
Many facilities had idiosyncratic policies about admission and retention. That
is, some administrators responded "it depends" when asked about whether the
facility would admit or retain residents with a specific condition. For
example, one quarter (26%) of the administrators responded "it depends" when
asked whether they would admit a resident with moderate to severe cognitive
impairment. One third (33%) reported that "it depends" when asked whether they
would retain a resident with moderate to severe cognitive impairment. When the
"it depends" response was given, it was counted as a "no" since
residents and families could not rely on either admission or retention in such
instances.

The item on admission and retention of
residents with urinary incontinence may have been misunderstood by the
respondents and interpreted as meaning residents who could manage their own
incontinence supplies. A subsequent report that used more detailed questions
may provide a more reliable indication of admission and retention policies with
respect to residents with incontinence

Assisted living facilities that specialize in
providing care to persons with Alzheimer's disease or other dementias or that
have a specialized care unit (SCU) may be the exception. Six percent of the
ALFs on multi-level campuses reported that a residential care SCU was part of
the campus. In addition, some of the free-standing ALFs may have had wings that
were SCUs or may have designated the whole facility as an Alzheimer's-specific
facility. The prevalence and characteristics of these facilities will be
explored in a subsequent report that provides data from more extensive
interviews with the administrators.

Source of the data for characteristics of board
and care home residents is Hawes et al., 1995a; for nursing home residents, it
is Krauss and Altman, 1998. It is important to note that the data are not
strictly comparable; therefore, they are merely suggestive of differences
between settings in resident case mix. The data on board and care home
residents are from interviews with the residents and direct staff caregivers in
512 facilities in 10 states (Hawes et al., 1995a). Moreover, they are not based
on a nationally representative sample of residents. Instead, they were drawn
from a stratified, random sample of board and care homes in states with
extensive or limited regulatory systems. The data on the characteristics of
nursing home residents is more directly comparable. It is drawn from a
nationally representative sample of nursing home residents in 1996 as part of
the Nursing Home Component of the Medical Expenditure Panel Survey (MEPS)
(Krauss and Altman, 1998).

The basic monthly rate does not include charges
for any ancillary services. According to prior studies, there is considerable
variation among ALFs in the nature and extent of services covered under the
basic rate (e.g., Gulyas, 1997; ALFA, 1998). The services covered by the base
rate and charges for ancillaries are explored in a subsequent project
report.

These income categories were calculated from
data provided by the U.S. Bureau of the Census (1998) for income of older
persons in 1997.

Later in this project, staff will conduct
follow-up interviews with a sample of residents who have "exited" assisted
facilities since the initial round of in-person interviews. These interviews
with discharged residents (or their next-of-kin) will provide better answers to
this question.

This appendix is a recreation of the questions
asked on the questionnaire. See the PDF version for a scanned version of the
form itself.

OTHER REPORTS AVAILABLE

A National Study of Assisted Living for the Frail Elderly:
Discharged Residents Telephone Survey Data Collection and Sampling
Report